losis by subcutaneous injection of iodoformed ether. In two cases of Pott's disease—one an enormous iliac abscess, the other a psoas abscess pointing in the thigh-rapid cure had followed the evacuation of the pus and the introduction of the iodoform, although in the former case some drops of ether had escaped into the abdominal cavity and caused peritonitis in a slight degree; and the cure had now persisted for some years. In two cases of hipdisease which required resection and subsequent scraping of numerous fistula which recurred, injection of iodoform caused a rapid cure. In a case of white swelling of the knee in which, on account of the rapidity of its progress, excision of the joint was considered advisable, rest and iodoform injections caused rapid closing of the sinuses and such amelioration of the symptoms that the patient, a lad of sixteen, can now walk about in a fixed apparatus, the local and general condition being perfect. Other cases in which good results followed were-tubercular ulceration of the tongue, white swelling of foot, and an empeyma in which a fistula persisted after the resection of portions of several ribs. M. Verneuil insisted on the necessity for the continuance of the iodoform treatment for some time after apparent cure in doses of 5 to 10 centigrammes, and drew attention to the point in using an ethereal solution that the canula should be retained in place for some little time to allow the escape of the vaporised ether and prevent undue distension of the sac. At the same meeting M. Redard drew attention to the good results he had obtained by the injection of iodoformed oil-10 parts in 100-which he prefers to ether. Out of 30 cases-26, tuberculosis of the bones-25 cures were noted.

These striking results in America and on the Continent ought to draw more closely the attention of surgeons at home to this method of treatment, which appears, at any rate, free from all risk.

XIV.-GASTROSTOMY.

In an admirable paper read before the Chicago Medical Society, and published in the Medical Recorder, January, 1892, Dr. Senn reviews the present position of this operation, basing his remarks on three cases of his own. As the result of an analysis of all the cases recorded (the operation only dates from 1849; Sédillot's case and many of the earlier cases belong to the pre-antiseptic era), the mortality from the operation is only about 25 per cent.certainly a good record for such a grave procedure; one, moreover, that is generally, and wrongly, only resorted to when the

patient's powers have sunk below rallying point. Now that the question of the relation of physician and operating surgeon in cases of this class is being so earnestly debated, perhaps we may be allowed here to emphasise the remarks with which Dr. Senn directs attention to the necessity of early intervention if a prolongation of life is to be hoped for. "The bad showing of the operation should only remind us not to postpone it until the patient has not sufficient recuperative powers left to rally from its immediate effects, and to secure a satisfactory repair at the site of operation.

The operation should never be delayed until the patient is on the verge of starvation." The various methods of performing the operation are discussed, and Fenger's incision is rightly, we believe, discarded, the incision at his site causing too great a drag on newly-formed adhesions, and accounting for many of the failures by rupture of the union after withdrawal of the mechanical supports employed. "The upper central part of the left rectus and the eighth intercostal space between the cartilages of the ribs are the most desirable points for the formation of the gastric fistula." The former is the incision advised by Von Hacker and practised by him in fifteen cases, fourteen of which were successful so far as the operation was concerned. The latter is the ingenious suggestion of Hahn (vide Berl. med. Wochenschr., No. 14, 1890), successfully adopted on eight occasions. In discussing the question of difficulty in finding the stomach, owing to the atrophy and diminution in volume of the organ which are so often present in cases of œsophageal obstruction, Dr. Senn refers to the mistakes that have been made, such as opening the duodenum and transverse colon, and recommends the distension of the stomach by gas after his method of intestinal inflation now so widely practised. But here he seems to forget the usual impermeability of the stricture, whether cicatricial or neoplastic, at the period when operative measures are resorted to, and the difficulty, not to say Hanger, of stopping in the middle of an operation of such serious nature to attempt catheterisation of the stomach. This seems a atal objection to a proposal which otherwise would solve an anxious problem. Dr. Senn is in favour of a two-step operation. En every case where delay is possible the fistula should not be established until the third or fifth day when adhesion will be firm enough to prevent gastric extravasation into the peritoneal sac. Meanwhile the patient must be supported by rectal feedingour ounces every four or five hours. A full description is given

of Witzel's ingenious suggestion for tunnelling-or rather forming an artificial tunnel in-the stomach wall to prevent the leakage of the gastric contents and its concomitant troubles Witzel has employed this device in two cases with good result (Centralbl. f. Chir., No. 32, 1891).

Perhaps the most important question discussed by Dr. Senn is the performance of gastrostomy with a twofold object in view— the immediate saving of life in cases of cicatricial contraction of the gullet, and the subsequent "retrograde dilatation" of the stricture through the opening so obtained. This operation has already been done with a certain amount of success. In summing up the case for operation the author arrives at the following inportant, among other, conclusions:-"Gastrostomy for malignant obstruction on the proximal side of the stomach, if performed at a time when the patient is sufficiently strong to survive the imme diate effects of the operation, is a comparatively safe procedure. and adds from a few weeks to six or eight months to the patient's life." "Leakage from the fistula can be prevented most effectually by making the opening in the stomach small, by the use of an inflatable double rubber bulb through which the feeding tube reaches the stomach, or by making an oblique tunnel in the anterior wall of the stomach as devised and practised with success by Witzel." "Mastication of food, as a preliminary step to its introduction into the stomach, satisfies, at least in part, the sense of hunger, which is not always accomplished even by liberal exclusive gastric feeding through the fistula."

The essay it will be seen embraces all the most recent work on the subject and is worthy of careful attention. The subject is one that has always been of much interest to the writer since having had the opportunity of seeing Mr. Sydney Jones' cast alluded to by Dr. Senn in which the patient survived for forty days. If that case taught any lesson it was this-delay is fatal both to the patient and to the operation. Once again let it be urged that in early resort lies the only chance of success. Not only is the recovery from the operation more certainly assured. but much is gained by early removal of the mechanical irritation of food-a point not touched on by Dr. Senn, but one of the greatest importance, especially in the delaying of the evolution of malignant growths. Otherwise surgery can offer no relief to humanity in the passage of that most terrible of all paths that lead to the valley of the shadow of death-the path of starvation.

PART IV.

MEDICAL MISCELLANY.

Reports, Transactions, and Scientific Intelligence.

CLINICAL RECORDS.

A Case of Protracted Enteric Fever. By R. J. KINKEAD, B.A., M.D., Univ. Dubl.; Professor of Obstetric Medicine and Lecturer in Forensic Medicine in Queen's College, Galway.

THREE hundred years ago (1591) Forestus described the disease, which we now call enteric fever, under the name Febris lenta, from its long furation. In 1729 Strother, in his "Very Remarkable History of a Spotted Fever," spoke of the "Slow" or "Lent Fever," which could have een none other than enteric fever. Protracted as the duration of this ever not infrequently is, the following case is probably without a arallel. The patient was admitted to hospital after five weeks' illness, and was discharged convalescent after a sojourn in hospital extending ver 18 weeks and 5 days.

CASE.-Mrs. X., aged fifty-two, mother of a large family, a very stout woman, was admitted to hospital on Oct. 2, 1891, and discharged on Feb. 9, 1892. Five weeks before admission diarrhoea began, notwithtanding which she went to Dublin, remained there three or four days, ame home, and had no medical advice or treatment for three weeks. he was then seen, prescribed for, and directed to remain in bed; but iarrhoea getting a little better she got up, went out, and continued at er household duties until Oct. 1, when diarrhoea still persisting, and eling weak, she again sought advice.

All the symptoms of typhoid fever were well marked; numerous pots, abdomen tympanitic, pain, tenderness, and gurgling in right iliac ossa; temperature, 101.6°, rising to 103° in evening; stools, "peaoup;" the urine scanty, of low specific gravity, and albuminous. Abdominal distension and pain increased, vomiting followed, and on Oct. 8 the respirations became slightly hurried. On morning of 9th here was dulness on percussion, and fine crepitus over base of left lung, p to within a couple of fingers' breadth of angle of scapula, extending

round to sub-mammary region; the pulse was weal the first cardiac sound short, but fairly good, the se tuated; mind clear, but patient very fretful and nervous The urine steadily diminished in quantity; the albu of lungs, the distension of the abdomen as steadily inc dry and dark brown, the face puffy and flushed, when hæmorrhage from the bowels occurred. On that day, ing, she had six stools, at first nearly all liquid blood, gradually getting more fæcal and less bloody, until ther last couple of stools on the 14th.

Although she was very much weakened by it, yet o hæmorrhage proved beneficial. The kidneys were dis the quantity of urine increased; the albumen diminishe the specific gravity rose. At the same time the lung sym dulness and crepitus diminished, respirations became de the temperature steadily fell, the abdomen was less dis patient progressed fairly well until Oct. 27-then she bec before. Both lungs were now engaged, dulness and bases; respirations 36 to 40 per minute; pulse rapid, cardiac sounds short and weak, with a peculiar, musica bruit at apex; frequent liquid stools, sometimes passed scanty, albuminous, of low specific gravity; and occas bladder power requiring use of catheter.

On Nov. 8-38 days after admission, 26 days after form second attack of hæmorrhage from bowels occurred, an carried off the patient; it was decidedly more profuse, than the first, and reduced her to a profoundly prostr However, she rallied, and the record for Nov. 9 to Dec steady continuance of fever, with apparently abortive defervesce, most disheartening to deal with. If lungs i kidneys worked worse, or the abdominal symptoms became if abdominal distension declined, diarrhoea lessened, and te so marked, she would either take to vomiting, or the lung ahead, and urine become scanty; if kidneys acted better, eit abdomen gave trouble, and sometimes all together got bad failed, and the patient's condition appeared hopeless, while fresh spots kept coming out as the old ones faded away. the stools began to thicken, and between 30th and 31st the fell from 103.8° to 97.2°.

The fall in temperature was followed by an all-round imp The lungs cleared up, and respiration became normal; urin abundant, and free from albumen; the pulse fell in rate, an fuller in volume; tongue became clean and moist; abdominal disappeared, and stools became solid.