It never occurred to me to do otherwise; and I cannot recollect any one of my teachers so slipshod in his work as to have suggested it.

One can, of course, confirm the observations of Dr. Duane regarding the often great difference in the refraction of the two eyes, the frequent obtaining of great relief and of binocular vision after careful correction for constant wear, and the recognised fact that small differences between the two eyes often give rise to more suffering than great differences. Parallel

to this last is the fact that small errors of refraction are answerable for more headaches than large ones. Dr. Duane himself, does not appear to me to claim in his excellent paper the originality attributed to him by your periscopist. Yours faithfully,

Brisbane,

25th February, 1902.

J. LOCKHART GIBSON.

a

[The above caustic criticism from so well-known, and able an ophthalmic surgeon, and so fair-minded man as Dr. Gibson, is puzzling. The writer is quite content to adhere to his statements and opinion, for he is in good company. Were it not manifestly otherwise, he would like to think that the explanation of Dr. Gibson's letter might lie in his misapprehension of the sense in which the word anisometropia was, and is generally, used. Of course, slight differences in each eye (up to about 1.5 D.), are always separately corrected. But the paragraph in the Gazette referred to cases up to 11D. Moreover, Dr. Gibson has read the original article, in which Duane clearly states that he has "for the most part, included only such cases as showed a difference of at least 2D." The term, anisometropia, is not generally applied to slight differences, or nearly all cases of ametropia would be included under that head. The whole point of Duane's paper is that he gives each eye its own correction in inequality of high degree. Dr. Gibson says that in 17 years he has never done anything else than correct each eye in anisometropia (he must include a large number of cases of high degree), and in most emphatic and unmistakable language, he says that this is the only recognised practice. Well, Donders, Landolt, Fuchs, Swanzy, Norris and Oliver, Meyer, Fick, Roosa. Nettleship, Brudenell Carter, and, in fact, every accessible authority say it is not, and funnily enough, so does Dr. Duane himself in the paper referred to. Dr. Gibson can surely not have read very carefully this paper, of which he so highly approves, for the opening paragraphi begins: "There is still such considerable difference of opinion with regard to the management of cases of anisometropia that there seems little reason to apologise for offering my personal experience in the matter. am the rather led to offer mine, because it seems to differ more or less from that of others who have written upon the subject, and particularly because it runs counter to the statements contained in many of the text books." So it appears that Dr. Duane does claim that his practice is not the usual one. ("Originality" was not attributed to him). It is unnecessary to quote all the above-mentioned authorities.

I

Two will suffice. Fuchs says (Text Book of Ophthalmology): "The obvious course to pursue would seem to be to correct the anisometropia by ordering different glasses for the two eyes. Nevertheless, this measure, in most cases, proves impracticable. . . We

with correction of the least ametropic eye, or of that which has the best vision, or we may particularly correct the most ametropic, and fully correct the least ametropic." All the other authorities say practically the same thing. Surely these men are worthy of the name of ophthalmic surgeons,' and "take their refraction work seriously," and do not teach in a "slipshod" way. With Dr. Gibson's practice in these cases the writer, in general, agrees, and has followed it himself for some years with good results in many cases. He was gratified to find Duane and Dr. KentHughes endorsing it, and is also pleased to find Dr. Gibson also believes in it. When, however, Dr. Gibson says that this is the usual course in all cases of anisometropia, he cannot follow him, when Duane himself, all the available text books, and his own ophthalmic acquaintances, say it is not.-PERISCOPIST.]

MEDICO-LEGAL.

Employers' Liability for Contracting Infectious Diseases.-On January 29th, at Sydney, in Chambers, Mr. Justice Stephen considered an application on behalf of William A. Kennedy for leave to proceed against the Australian Drug Co., Ltd., under the provisions of the Employers' Liability Act. He was a glass-blower, and his work required him to blow through a glass tube, which was handed from workman to workman. He contracted a certain disease, which manifested itself in the form of a sore near the mouth, It was alleged that three or four cases of the same sort had occurred in the works, and his legal advisers claimed that the plant of the company was defective in that the glass tube had not been kept in a sanitary condition, and this negligence had caused the injury. The judge decided that the application could not be granted, as the notice of intention to proceed should have been given within six months after the injury had been sustained. The second case, heard on February 5th, was brought by Robert G. Kennedy, an apprentice. For the defendants it was urged that sec. 3 of the Employers' Liability Act did not apply to apprentices. The judge held that this contention was sound, and application was refused, with costs.

Sydney Metropolitan Medical Association.At a meeting of this Association held on March 17th, a resolution was passed that this Association should nominate one medical practitioner engaged in Lodge practice as their representative on the Council of the New South Wales Branch of the British Medical Asso

ciation, and that the Western Suburbs Medical Association be asked to nominate one representative instead of two, as heretofore. A ballot was taken, and resulted in the selection of Dr. E. H. Binney as the nominee.

An Unfortunate Experience.-A correspondent writes informing us he has had an unpleasant and unprofitable experience through taking charge of a country hospital in New South Wales, and he would caution his confrères against entering into a similar contract. He signed an agreement for twelve months, and found there was little or no private practice to be obtained in the neighbourhood, and consequently the salary paid by the hospital authorities was insufficient. He complains also that "encouragement was given to two unqualified men, one of whom was elected to the committee. Such an experience, unfortunately, is

same glasses for both eyes, or to correct one eye, and place a plane glass before the other." Swanszy says: "When the difference is considerable it is often impossible to correct both eyes. ... We must then be content

inquire carefully into the circumstances and surroundings of any such an appointment before binding themselves by signing an agreement.

As

John Fawcett, M.D., and F. J. Steward, M.S., record the above (Clinical Society's Transactions, Vol. xxxiv., 1901). The patient, a boy of eight, was admitted to Guy's Hospital with signs of lobar pneumonia at the right base, six days after commencement of illness. The following day there was slight increase of præcordial dulness, and this gradually increased, till, at the end of ten days, it reached the first intercostal space above, one inch to the right of border of sternum, and on the left, two inches outside nipple line. There was at first a soft "to and fro" bruit at the apex, and the sounds became more muffled. The temperature ranged from 98° to 101° F. The signs at the base were disappearing. The upper portion of the epigastrium became more prominent and was very tender on pressure. The cough again became frequent and severe, and the pulse and respiration rate had increased. the boy was becoming visibly thinner, and was eating and sleeping badly, it was decided to explore the pericardium. A needle was inserted in the fourth left space, about one inch from the margin of the sternum, and thick yellow pus was withdrawn. A few hours later the pericardium was opened under A.C. E. through an incision over the fifth costal cartilage. The perichondrium was stripped off, and about one inch of the cartilage removed. No pleura came into view, but the pericardium was easily seen and incised. About eight ounces of thick pus were evacuated; a short thick drainage-tube was inserted and dressings applied. The operation only occupied a few minutes. A large quantity of pus drained away during the first twentyfour hours, but gradually lessened, so that after the fifth day very little came away. An attempt was made to keep the boy on his face, to assist drainage, but had to be abandoned. The child's general condition improved very much during the first ten days, his cough became less troublesome, his pulse stronger, and he ate and slept much better. A localised empyema was found on the right side, which was opened and drained fourteen days after the first operation. The child again improved for a while, but died five days later, or nineteen days after the pericardium was opened. The authors state that the post-mortem examination clearly demonstrated that the proper treatment was adopted, as the pericardial sac, which must have held about ten ounces of pus at first, had become practically obliterated. A reference is given to a paper by C. B. Porter (Annals of Surgery, December, 1900) giving 51 cases, or with the present 52, of which 20 recovered and 32 died.

Traumatic Subdural Hæmorrhage, Occasioning Convulsions on the Sixth Day after Injury, and Successfully Treated by Operation.

Raymond Johnson, B.S., and J. Risien Russell, M.D. (Clinical Society's Transactions, Vol. xxxiv., 1901) record the above case. The patient, a porter at. 33, was admitted to University College Hospital October 23rd, 1901, suffering from frequently recurring

convulsions, affecting chiefly the left side of the body. Six days previously he fell whilst carrying a sack of potatoes down a flight of stone steps, and was found unconscious at the bottom of the steps, bleeding slightly from a scalp wound on the left side of the head. He was slightly under the influence of drink. He was got to bed, and remained unconscious till the next morning, when he woke up and walked to see a shaken by the fall. He remained away from his work doctor. He complained of headache and of being for five days, but apparently without any definite symptoms until 10 o'clock the night before admission, when he had a fit, and continued to have_rapidly repeated fits until he was admitted to the Hospital. On admission he was bathed in perspiration, temperature 102° F., pulse 100. Each fit lasted from two to four minutes, with an interval of from one to five minutes, and the mode of onset was either the turning of the eyes to the left, or twitching of the left side of the face. The clonic spasms rapidly involved the whole of the left side of the body and the right leg. During the fits the patient sweated profusely, and was deeply cyanosed. In the intervals he could usually answer questions. Pupils equal, of medium size, and reacted normally. The left arm was distinctly weaker and more flaccid than the right. The arm-jerks were present on the left side but not on the right. On the left side there was exaggeration of the knee-jerk with ankle clonus, and the extensor response was obtained as the plantar reflex. Chloroform was administered for half-an-hour on two occasions, and checked the fits each time, but they returned as soon as it was stopped,

On

A full dose of chloral and bromide was administered per rectum. In arriving at a diagnosis uræmia was quickly excluded. Epilepsy, however, caused more serious consideration, as the father and brother had both suffered from it; but as many of the fits began by twitching of the left side of the face, and others by movements of the left hand, this mode of onset, coupled with the state of the reflexes, and the paresis of the left arm before mentioned, was regarded as indicating the existence of a definite irritation of the right cerebral hemisphere. The evidence did not justify the diagnosis of a focal lesion, as the fits did not constantly begin in the same region. The late onset of the fits also seemed to negative the presence of a clot of blood, so that the recorders were forced to the conclusion that the lesion was probably inflammatory in nature. It was decided to expose the right hemisphere over the middle of the Rolandic area. removing a disc of bone with an inch trephine, the dura mater was found to bulge slightly, and to present a bluish tint. On incising the dura a small quantity of thick dark blood escaped. The opening in the skull was enlarged upwards and downwards with bone forceps, and the opening in the dura opened in a crucial manner to the full extent of the bone opening. In all, between two and three drachms of blood escaped. The surface of the brain presented a perThe divided dura was fectly normal appearance. turned into position, and the scalp incision sutured. No bone was replaced. No fits occurred after the operation. Considerable weakness of the left side, especially of the arm, followed, and it was nearly a month before the arm had fully recovered its strength. The extensor response on the left side was present for four days after the operation, and the right pupil was larger than the left for six days. The temperature rose to 105° four hours after the operation, and for four days varied between 101.4° and 104°, and after the sixth day was normal. The patient left the hospital on the 34th day in perfect health.

Ano-Rectal Transplantation. RUSHMORE, of Brooklyn (Annals of Surgery, December, 1901), briefly relates a case of the above, where very satisfactory results were obtained. The patient, a male aged 39, had five months before, while bending over his work, been gored in the rectum by a bullock, which caused a lacerated wound through the sphincter, and both backward and forward into the perineum. The loss of blood was sufficient to weaken him. Several operations had been performed in New York, Boston and Chicago, but without any material relief. He had no control over the sphincter, and was consequently always in a filthy state, and unable to work. The sphincter manifested no contractile power whatever on inserting the finger into the rectum, nor could the patient by any voluntary effort cause it to contract in the slightest degree. Inguinal colotomy and anorectal transplantation were the only two methods of treatment likely to do good. As it was desired to restore the man to a condition fit for active work, the latter operation was decided upon, after explaining to him its experimental character. With the patient on his side, under ether, an incision was made extending from about a quarter of an inch outside the anus following the natal cleft to the sacro-coccygeal articulation. The coccyx was removed and the rectum, including its middle and lower third, freed from the surrounding soft parts posteriorly and laterally, and the hæmorrhage checked by torsion. The patient was then put in the lithotomy position, and with an assistant holding a sound in the urethra, the anterior portion of the rectum was separated by means of scissors well up to Douglas' cul-de-sac. The anal end of the rectum was then anchored in the upper angle of the wound, ust below the sacrum, by means of black silk sutures. The wound below the upturned rectum was theu irrigated and stitched. The result of the operation was a rectal pouch, the bottom of which was about three inches below the transplanted anus, and the posterior wall of the rectum was folded back on itself and formed a thick valve just inside the anus. The operation was followed by a good deal of pain for a few days, and some suppuration, but the ultimate result was very good, the patient gaining strength and weight, and was able to resume work.

Pylorectomy performed in two stages.

GORDON (Medical Press and Circular, January, 1902) reports a successful case of pylorectomy performed in two stages. The patient, a man aged 43, had suffered from vague gastric symptoms for about 20 months. The pain was never severe, nor was vomiting constant. He had lost 21 lb. in weight during the last four months. A tumour was to be felt in the abdomen, just above the umbilicus; it measured about three inches in transverse diameter, was hard and irregular, and could be felt to move readily with respiration. It could be moved freely in all directions. There was no liver enlargement; and this, together with the remarkable mobility of the tumour led to the hope that there was an absence of adhesions and of secondary cancer deposits. An incision was made slightly to the left of the middle line. A hasty examination of the tumour justified the hope that had been entertained. The transverse colon was turned upward and posterior gastro-enterostomy performed. The opening in the stomach was made as far to the left as possible, after the method of Roux. The jejunum was divided some distance from the duodenal flexure, the lower end was fixed to the stomach opening, and the upper end was made to anastomose with the jejunum again some four inches or more from the stomach junction. Simple

suturing was used throughout. The abdomen was then closed. The course of the case was satisfactory; there was little or no shock, and the patient only vomited once. By the ninth day he was able to take solid food. Twenty-five days after the gastro-enterostomy the abdomen was again opened in the middle line by an incision five inches long. When the stomach region was exposed, an opening was made in the lesser omentum in order to explore the posterior aspect of the tumour. A Doyen's clamp was placed across the duodenum, which was cut across, and the end at once sewn up by a double row of silk sutures. The stomach was then cut across between clamps placed well beyond the apparent limits of the growth, and the opening closed up by a double row of silk sutures.

There was very little loss of blood during the operation, which lasted one and three-quarters of an hour. The excised portion of stomach showed a considerable narrowing of the pylorus by a growth which proved to be a columnar celled cancer. The patient's condition for some days after the operation was a precarious one. His temperature went to 102° F. and his pulse to 160 on one occasion. On the fourth day a free discharge of bilious fluid occurred from the bottom of the first incision; but the general condition of the patient improved. At the end of the first week a considerable increase in the nourishhment was risked, and it was found that he could take four pints of peptonised milk in the day without any discomfort. Steady improvement took place, and the patient gained 12 lb. in weight in four months.

"Is

The author in his remarks discusses the question pylorect my under any circumstance legitimate?" and comes to the conclusion that it is, provided the operation can be performed early. He briefly summarises as follows:

1. The present position of pylorectomy is unsatisfactory, but there is no cause for despair.

2. That an advance may be made, it is, in the first instance, necessary to reduce the immediate mortality. This is to be done by (a) a more careful selection of cases, and (b) by performing the operation in two stages. In the second place it is necessary to obtain better ultimate results. The way to this end lies in (c) wider resections, and (d) in this case also in better selection of

cases.

3. Let these things be accomplished and we may then, with more justice than at present, call upon physicians to resort more frequently to exploratory operation.

THERAPEUTICS.

The Treatment of Cardiac Dilatation and Asthenia.

Burney Yeo (Practitioner, January, 1902), points out that there are three manifest causes which have been at work in recent years in giving rise to the prevailing tendency to cardiac asthenia and dilatation, (1) the influenza epidemic; (2) abuse of muscular exercises; (3) excessive use of tobacco. The two last differ from the first in being entirely preventible. The incidence of influenza is, of course, to a great extent unavoidable, but in dealing with the period of convalescence after this disease, sufficient stress has not been laid on the necessity of a prolonged period of physical rest; for, while it may be altogether advantageous for the patient to be much in the fresh air, active physical exercise should certainly be forbidden. Physical exercise has its place and season in the treatment of cardiac debility, but it is often applied

out of place and season. Physical rest in bed has ever been, and ever will be, the surest of all cardiac tonics in serious cases of cardiac dilatation and asthenia, and this is the most essential remedy in the early periods of commencing dilatation. When exercise becomes desirable and necessary, gentle carriage exercise is of real value, and also horse exercise for those who are accustomed to it. The author has found the use of saline baths containing carbonic acid at temperatures from 88° to 93° F. beneficial in cases of chronic cardiac asthenia and dilatation following upon acute disease, and also in nervous persons with dilatation from strain and over-exertion, mental and physical. With regard to general considerations as to the appropriate treatment of cases of cardiac dilatation, in the first place the patient must be withdrawn from the influence of all those conditions which have caused it. If it has been due to over-exertion, then there must be avoidance of all kinds of muscular effort and only gentle exercise allowed. If it has been induced by over-excitement, either mental or emotional, or addiction to evil habits, these causes must be sought out and corrected. An open-air life in the country, or at the sea-side, gentle exercise, a nourishing but light and digestible diet, regular action of the bowels, and early retirement to bed are all very obvious but necessary remedial measures. Some form of cardiac tonic is generally indispensable in these cases, specially in those which follow attacks of acute febrile and septic diseases, and also in anæmic conditions. If there be much dyspnoea and troublesome palpitation, small doses of digitalis with iron may be given, but the author prefers to employ strophanthus, or strychnine, with coca, in combination with iron, quinine, or arsenic, as may seem desirable. In purely anæmic cases, iron and nux vomica with some aperient will be most appropriate. In cases of acute dilatation, however induced, the hypodermic injection of strychnine in doses of th to th of a grain will often be attended with remarkably good results. Free action of the bowels is very advantageous in nearly all cases of cardiac dilatation and feebleness, but aperients must be so given as to clear away only the residue of digestion. For this purpose the best method is to give an aloetic pill after dinner or at bedtime, and a saline dose early in the morning, about an hour before breakfast.

Suprarenal Extract in Cardiac Conditions.

Deeks (Montreal Medical Journal, November, 1901), gives the history of two cases in which he used the suprarenal extract with good results. The first case was a female patient, eighty-two years of age, suffering from the symptoms of dilatation of the heart. The cardiac action was weak and irregular, the legs much swollen, the cedema persisting in spite of rest in bed. The diagnosis was myocarditis, mitral incompetence and arterio-sclerosis. All the usual remedies had been tried with no benefit. Vomiting set in, and the patient's condition became extremely serious. Suprarenal extract in three-grain doses was ordered, and from the first day a marvellous improvement was observed. The vomiting ceased, the swelling disappeared, and the patient was soon able to walk. The heart's action became regular, and the patient was better than she had been at any time during the preceding three years. She took from nine to eighteen grains of the extract each day. The second case was a man seventy-six years of age, with oedema of the legs, heart regular but rapid, with weakness of the first sound. Under the use of suprarenal extract, the dema entirely disappeared in six weeks, and the

heart's action much improved. In both of these cases the extract had only been given as a last resource, the usual cardiac tonics having failed to effect any improvement. These results are somewhat remarkable, in view of the known action of this remedy in raising arterial blood pressure, since with a weakened myocardium and degenerate vessels one would rather have expected unfavourable results-either a rupture of the blood-vessels, or fatal syncope from over-strain of the cardiac musculature.

Creosotal in Pneumonia.

Leonard Weber (New York Medical Record, November 2nd, 1901), relates his experience with this remedy in the treatment of nine cases of pneumonia, both lobar and lobular. The ages of the patients ranged from twenty to forty-seven years. The oldest patient died from cardiac degeneration, but all the others recovered. The course of the disease so treated shows that this drug exercises a remarkably beneficial and uniform influence. There were no symptoms of depression or disturbance of the gastro-intestinal tract. As soon as the patient came under the full influence of the drug the temperature fell, and the same improvement ensued as usually supervenes at the onset of the crisis. It is doubtful if the drug exercises any direct

curative effect on the disease. The author administered the remedy in capsules containing ten minims six times a day, in some cases for eight days.

The Clinical Uses of Citrophen.

No

Syers (Treatment, January, 1902), relates his experience of the use of citrophen in various conditions. He has found it of great service in the treatment of the headache of anæmic girls. In most cases one tengrain dose has been followed by a relief of the pain, and, as a rule, two or three doses of the same amount have cured the headache for the time being. unpleasant symptoms have ensued. In migraine, it has seldom failed to give relief and frequently has cut short the attack. In neuralgia, generally the relief has been only temporary, and no permanent cure of this condition has been observed by the author. But he has obtained excellent results in the relief of the various aches and pains so frequently met with in neurasthenics. In lumbago and sciatica 15-grain doses given every three hours up to three doses have nearly always proved beneficial in removing the pain, at any rate, for the time being. In chronic articular rheumatism a dose of ten grains given night and morning has relieved the pain when other remedies have all failed. The author also has found it useful in the severe head pains at night in patients suffering from syphilis. In febrile diseases citrophen is certainly useful; in some cases of pleurisy in which the pain was very severe it was greatly relieved or entirely removed by a few 10-grain doses. On the other hand, the author has not found it to be of much service in reducing temperature-neither in acute rheumatism nor in pulmonary inflammations, acute or chronic-has the author's experience proved it to be superior to other remedies. Nevertheless, the very marked power of relieving pain in many and various morbid conditions which citrophen undoubtedly possesses renders it a valuable addition to the list of drugs in ordinary daily use. It is pleasant to take, and can be adminis tered in effervescent waters. It has no depressing or deleterious effect, and the author has never observed the slightest ill effect as the result of its use.

Ano-Rectal Transplantation. RUSHMORE, of Brooklyn (Annals of Surgery, December, 1901), briefly relates a case of the above, where very satisfactory results were obtained. The patient, a male aged 39, had five months before, while bending over his work, been gored in the rectum by a bullock, which caused a lacerated wound through the sphincter, and both backward and forward into the perineum. The loss of blood was sufficient to weaken him. Several operations had been performed in New York, Boston and Chicago, but without any material relief. He had no control over the sphincter, and was consequently always in a filthy state, and unable to work. The sphincter manifested no contractile power whatever on inserting the finger into the rectum, nor could the patient by any voluntary effort cause it to contract in the slightest degree. Inguinal colotomy and anorectal transplantation were the only two methods of treatment likely to do good. As it was desired to restore the man to a condition fit for active work, the latter operation was decided upon, after explaining to him its experimental character. With the patient on his side, under ether, an incision was made extending from about a quarter of an inch outside the anus following the natal cleft to the sacro-coccygeal articulation. The coccyx was removed and the rectum, including its middle and lower third, freed from the surrounding soft parts posteriorly and laterally, and the hæmorrhage checked by torsion. The patient was then put in the lithotomy position, and with an assistant holding a sound in the urethra, the anterior portion of the rectum was separated by means of scissors well up to Douglas' cul-de-sac. The anal end of the rectum was then anchored in the upper angle of the wound, ust below the sacrum, by means of black silk sutures. The wound below the upturned rectum was theu irrigated and stitched. The result of the operation was a rectal pouch, the bottom of which was about three inches below the transplanted anus, and the posterior wall of the rectum was tolded back on itself and formed a thick valve just inside the anus. The operation was followed by a good deal of pain for a few days, and some suppuration, but the ultimate result was very good, the patient gaining strength and weight, and was able to resume work.

Pylorectomy performed in two stages.

GORDON (Medical Press and Circular, January, 1902) reports a successful case of pylorectomy performed in two stages. The patient, a man aged 43, had suffered from vague gastric symptoms for about 20 months. The pain was never severe, nor was vomiting constant. He had lost 21 lb. in weight during the last four months.

A tumour was to be felt in the abdomen, just above the umbilicus; it measured about three inches in transverse diameter, was hard and irregular, and could be felt to move readily with respiration. It could be moved freely in all directions. There was no liver enlargement; and this, together with the remarkable mobility of the tumour led to the hope that there was an absence of adhesions and of secondary cancer deposits. An incision was made slightly to the left of the middle line. A hasty examination of the tumour justified the hope that had been entertained. The transverse colon was turned upward and posterior gastro-enterostomy performed. The opening in the stomach was made as far to the left as possible, after the method of Roux. The jejunum was divided some distance from the duodenal flexure, the lower end was fixed to the stomach opening, and the upper end was made to anastomose with the jejunum again some four inches or more from the stomach junction. Simple

suturing was used throughout. The abdomen was then closed. The course of the case was satisfactory; there was little or no shock, and the patient only vomited once. By the ninth day he was able to take solid food. Twenty-five days after the gastro-enterostomy the abdomen was again opened in the middle line by an incision five inches long. When the stomach region was exposed, an opening was made in the lesser omentum in order to explore the posterior aspect of the tumour. A Doyen's clamp was placed across the duodenum, which was cut across, and the end at once sewn up by a double row of silk sutures. The stomach was then cut across between clamps placed well beyond the apparent limits of the growth, and the opening closed up by a double row of silk sutures.

There was very little loss of blood during the operation, which lasted one and three-quarters of an hour. The excised portion of stomach showed a considerable narrowing of the pylorus by a growth which proved to be a columnar celled cancer. The patient's condition for some days after the operation was a precarious one. His temperature went to 102° F. and his pulse to 160 on one occasion. On the fourth day a free discharge of bilious fluid occurred from the bottom of the first incision; but the general condition of the patient improved. At the end of the first week a considerable increase in the nourishhment was risked, and it was found that he could take four pints of peptonised milk in the day without any discomfort. Steady improvement took place, and the patient gained 12 lb. in weight in four months.

The author in his remarks discusses the question "Is pylorect my under any circumstance legitimate?" and comes to the conclusion that it is, provided the operation can be performed early. He briefly summarises as follows::

1. The present position of pylorectomy is unsatisfactory, but there is no cause for despair.

2. That an advance may be made, it is, in the first instance, necessary to reduce the immediate mortality. This is to be done by (a) a more careful selection of cases, and (b) by performing the operation in two stages. In the second place it is necessary to obtain better ultimate results. The way to this end lies in (c) wider resections, and (d) in this case also in better selection of

cases.

3. Let these things be accomplished and we may then, with more justice than at present, call upon physicians to resort more frequently to exploratory operation.

THERAPEUTICS.

The Treatment of Cardiac Dilatation and Asthenia.

Burney Yeo (Practitioner, January, 1902), points out that there are three manifest causes which have been at work in recent years in giving rise to the prevailing tendency to cardiac asthenia and dilatation, (1) the influenza epidemic; (2) abuse of muscular exercises; (3) excessive use of tobacco. The two last differ from the first in being entirely preventible. The incidence of influenza is, of course, to a great extent unavoidable, but in dealing with the period of convalescence after this disease, sufficient stress has not been laid on the necessity of a prolonged period of physical rest; for, while it may be altogether advantageous for the patient to be much in the fresh air, active physical exercise should certainly be forbidden. Physical exercise has its place and season in the treatment of cardiac debility, but it is often applied