The method described as 2 is the one adopted in the above case, and is that which in my opinion will yield the best results. The operation is simple and not meddlesome, free in itself from danger, and can show a creditable list of successes, even to the ultimate closure of the resultant fistulæ. Number 1 I discard, because I fail to see what real advantage is gained by it. A case which recovers after this procedure would, I venture to think, get well if left entirely to nature. I have no great objection to 3 except that it appears to me by cutting into living intestine and mesentery we run too much risk for too little gain.

Number 4 may be regarded as the most complete, as it is the most fashionable of these operations; but it does not necessarily follow that it is therefore the best for the patient. None would deny for a moment, when enterectomy is perfectly successful, that it is far away preferable to enterostomy; but the comparative danger of the former more than outweighs its possible advantages. I know of several unpublished cases where gangrenous bowel has been treated by immediate enterectomy, and in every instance death has followed. A few successes have been published; but if we knew of the whole number where this operation has been performed, I do not hesitate to say that the death-rate would be found excessively high; and I am afraid it will always remain So. No analogy can be drawn from what is possible in formally planned enterectomy, where a patient may be specially prepared, and the absolute healthiness and emptiness of his bowels secured beforehand. In the case of gangrenous hernia we do not exsect through a healthy bowel wall; all we can look to is that the intestinal tissues are living. Life and health are here, as elsewhere, not essentially synonymous. It will usually happen that we have to suture a distended, irritated, congested, possibly inflamed gut end to another of unequal calibre, collapsed and altogether in a different condition of pathological disturbance. Again in the case of hernia the proximal intestine is always distended by a flood of thin, highly irritative liquid fæces, which rushes over

the newly formed junction when the gut is returned into the peritoneum, and being resisted by the contracted tube below, a great pressure is thrown upon the bowel sutures, and fæcal leakage is very liable to occur. This difficulty may of course be avoided by partially emptying the open intestine before the suturing is begun; but then we should have thin liquid fæces "playing about" with an opening in the peritoneum, a state of things, to say the least of it, not free from risk.

In those cases where an artificial anus has become established and the urgent symptoms due to the obstruction have passed away, it becomes a question what is to be done with the fæcal fistula. Experience teaches us that many such cases get well of themselves. The fæcal-way through the lower bowel becomes established, the artificial opening gradually contracts, and at last heals completely over. In a certain number, however, although the distal intestine may resume its function, the fistula continues open, and then we have to decide upon the necessity of operative interference for its closure, by the effect of the discharge upon the patient's general condition and by the amount of discomfort to which it gives rise. Most fistulæ which remain persistently open will be found to possess a spur, and when such is the case we have choice of two procedures.

1, Dupuytren's well known operation of enterotomy, and 2, the more modern plan of enterectomy, either at the wound or through a separate abdominal incision; as to which is the better, subsequent experience alone will teach us. The number of successes claimed by the former greatly outnumbers those of the latter, but whether this is proportionate only I have no means of ascertaining. The opponents of Dupuytren's operation contend that during the introduction of the blades of an énterotome we are liable to take in any coil of intestine which may chance to lie between the layers of the éperon, and crush it when the instrument is closed. I think this is extremely unlikely to occur, if the blades are made "to nibble" their way along the septum instead of being pushed in widely apart and shut down at once upon whatever may happen to be in their

grasp. Except for this possible accident Dupuytren's operation is comparatively free from danger and in the above case it was practically painless. It was accompanied by no ill effect upon the constitution, and it was followed by complete and satisfactory recovery. I think, therefore, where the patency of a fæcal fistula appears to be determined by the presence of a spur, that this should be freely divided-even although more than one application of a crushing instrument may be necessary -before resort is had to the more hazardous proceeding of enterectomy.

SURGICAL CASES.

UNDER THE CARE OF MR. GILBERT BARLING, F.R.C.S.

Case I. Renal Calculus. Exploration of Kidney. Failure in Discovering Stone.-A., male, aged 44, was sent to me in April, 1887, by Dr. Lyster, of Coleshill, with the following history:-For a year or more he had suffered from discomfort in the left loin, and three months previously he had an attack of renal colic, commencing with pain in the back, passing down the course of the left ureter to the upper part of the thigh and scrotum. The pain was accompanied by shivering and vomiting, but no blood was observed in the urine. The patient soon returned to work, although suffering from persistent pain in the left loin.

When I first saw A. he was stout and robust looking, but had given up work on account of his pain, and has not resumed it up to the present time. Pain was complained of in both loins, but especially in the left, and there was slight pain at times in both thighs, in the scrotum, and at the base of the sacrum. There was tenderness, on pressure, over each erector spinæ for a space of two or three inches at the level of the kidneys, and there was an especially tender spot at the base of the sacrum. The urine was slightly acid, clear, sp. gr. 1,015, no albumen, no blood, no pus, no crystals, but phosphates were precipi

tated on boiling. At this, my first interview, I had some doubt, from the diffuseness of the pain and tenderness and the condition of the urine, whether renal calculus existed, thinking that one had existed and been passed per urethram, and that rheumatism of muscles and fascia explained the symptoms; but on May 2nd the patient, after a severe attack of renal colic, passed a uric acid calculus, elongated in shape, very rough on the surface, and weighing twelve grains. After this the symptoms remained much the same, pain being always worse in the left than in the right loin, and tenderness still remaining over each erector spinæ and at the base of the sacrum and of the соссух.

On August 22nd I discovered a small, tender, hard swelling in the course of the left ureter, just where it crossed the brim of the pelvis, and which I regarded as possibly a small impacted calculus, but in September this had disappeared and, thinking it might have passed on into the bladder, I sounded for it but without result. Repeated careful examinations were made of the urine; the quantity passed varied from 44 to 72 ozs., and the sp. gr. from 1007 to 1028, but it was generally about 1016; occasionally there was a faint haze of albumen, once only were red corpuscles observed and never any pus cells. Sometimes crystals of uric acid, oxalate of lime, and phosphate of lime were present, but more commonly not. We pressed upon the patient the advisability of having the kidney explored for stone on account of his suffering and his incapacity for work, and though he had pain and tenderness on the right side yet everything pointed so strongly to the left kidney as the seat of the trouble that there was no hesitation in selecting this side for exploration.

On October 24th, therefore, assisted by Mr. Elliott, Dr. Lyster giving ether, I cut down on the left kidney by the ordinary transverse lumbar incision, some difficulty being experienced in reaching the organ owing to the stout build of the patient. The posterior surface of the kidney and pelvis were first explored with the fingers, then the anterior; the organ was large and very

By

firm, but no markedly indurated spot was found in it. means of a hare lip pin the kidney substance was systematically punctured on the posterior surface, but nothing was detected. Finally, an incision was made into the posterior surface of the kidney, near the lower end and somewhat closer to its internal than to its external border, and through this a silver probe was introduced and passed into a cavity with soft walls, which was searched in all directions but without detecting a calculus. Pressure for a few minutes having stopped the bleeding, which had been rather free, the wound was closed, two drains being inserted, one in front and the other behind the kidney. Recovery was rapid and uneventful, the highest temperature being 1005, and the patient being allowed to get up on the sixteenth day. For a short time after the operation the pain seemed decidedly less, but returned, and when the patient was seen, about three months later, the condition was as follows: pain in both lumbar regions and sometimes in the abdomen, marked tenderness also in the same area but specially on the left side, complaint of vague pains in both thighs and buttocks, occasional attacks of pain descending the left ureter, with shivering and vomiting. Urine acid, depositing phosphates on boiling, but free from crystals, blood, and pus. Dr. Lyster informs me that at present the symptoms are practically the same, but that the patient has recently become much thinner.

The failure in finding a stone may be due to the fact that none existed, but I believe the diagnosis was well founded, and in seeking to determine how a stone may have been missed I am inclined to ascribe it to one of three things. First, the incision into the kidney may have failed to open the pelvis and the finger stripping up the renal structure from the outside of the pelvis may have produced a cavity into which the sound passed. This happened in a case described by one of my colleagues whom I assisted in the operation; we both thought the pelvis had been opened but it was subsequently found that the pelvis was greatly dilated, that it had not been opened, that the kidney substance had been stripped off the pelvis, forming