BILHARZIA HÆMATOBIUM IN WEST AFRICA
659 vessels were caught up in time to stop free bleeding; they were tied with catgut; the oozing of blood was controlled. A large drainage tube was put in the whole length of the wound, and the edges of the wound were united by carbolised silk sutures. A Gamgee pad, oakum, and over this a bandage, were applied, and the patient was put to bed. As this man would have suffered had his opium been stopped, he was allowed to take enough to satisfy his cravings.-July 7th: The patient had a fairly
... t had a fairly comfortable night's rest, has no trouble in passing his urine.-July 8th : Has pain and fever. On the third day there was a good deal of swelling: the lower end of the wound looked unhealthy, and there was a sero-purulent discharge. Temperature 103°. The drainage tube was removed, the stitches at the lower end of the wound were cut to allow a free opening for discharge, and the wound was syringed out with 10 per cent. iodoform in glycerine. The patient complained of pain in both thighs near the pubes, no sign of any local trouble could be found there. On the sixth day he began to improve ; though he gained ground slowly, there was no further cause for anxiety.-Aug. 2nd : The wound is healed, except a small sinus in the track of the drainage tube. The patient has had perfect control over his urine all the time, and is much pleased at the relief from pain which has been afforded him by the operation. jEeMsrAs.—My patient is fifty-nine years old, and he is prematurely feeble from his opium habit. He is entirely relieved of the pain from which he formerly suffered, and has a good chance of freedom from the disease for the remainder of his life. Mr. Pearce Gould's operation has now been performed often enough to show that it is the operation most likely to prevent a recurrence of the disease. It is one that any surgeon can perform, and the haemorrhage is easily controlled. The one point where this case differs from the operation, as performed by other surgeons, is the making of a new urethra prior to the removal of the penis. In performing a severe operation on an old man enfeebled by disease, it was a distinct gain to have no danger of any trouble about the urethra. The patient made a good recovery, and I hope that other surgeons will give this method of performing the operation a fair trial. THE following cue, which may be compared with one published in THE LANCET of Jan. 1st, 1887, p. 17, was communicated (by the permission of Mr. Knox) to the Birkenhead Medical Society last winter. J. R-, aged three years, was admitted with Pott's curvature in the upper dorsal region of the spine. The last three months he had been unable to walk without supporting himself by the hands. The child held the head stinly, inclined to the left side; complained of pain on any movement of the head, and on pressure over the spinal projection. The breathing was accompanied by a stridulous, husky sound, both in inspiration and expiration, and there was aloud, brassy, short cough. His father stated that he had noticed this character of the breathing for some months. The tonsils and pharynx were red and rather swollen. In theevening after admission the respiratory difficulty was more apparent ; there was considerable recession of the lower part of the chest with inspiration; the stridor appeared to be partly nasal and partly laryngeal. There were no physical signs of disease in the chest. The child took food well, and the father stated that he had always done so. For the first four days that he was under observation the stridor varied somewhat from time to time. It was never great, and was almost absent when the child was undisturbed; it was sometimes more marked with inspiration, at other times with expiration. The respirations were 30 per minute. The inspiratory recession at the base of the chest continued ill varying degree. There was never any hoarseness in crying or speaking, the voice being unaffected. The child swallowed both liquids and solids freely, without any sign of difficulty. No prominence could be detected at either side ot the neck. There was no lividity of the lips or nails, and the temperature was about 100°F. On the sixth day after admission, with a rise of temperature, signs of pneumonia were developed, and the child rapidly became worse, with more cough and dyspnoea and the general aspect of broncho-pneumonia, which caused death two days later. Necropsy.-The body was well nourished. Both lungs were adherent to the chest wall and diaphragm, and their lobes to each other; the lower lobe of the left lung was consolidated. There were numerous caseating and calcareous glands around the trachea. Behind the oesophagus, and closely adherent to it, was a soft fluctuating tumour, oval in shape, larger than a horse-chestnut, in front of the vertebral column, and connected with it. The oesophagus was with difficulty separated from the front of the sac, having been compressed between it and the trachea. The situation of the abscess was fully an inch below the level of the larynx; it projected slightly to the left of the vertebrae, and a smaller sac passed from it to the right. The walls were thick and well defined, and when incised about half an ounce of thick white pus escaped. Forming the back of the abscess sac the bodies of the seventh cervical and first dorsal vertebrae were found to be almost destroyed, and the front of the bodies of the following two dorsal vertebrae was also carious. ReMay'.—The abscess in this case was due to one of the common causes of retro-pharyngeal abscess--viz" disease of the vertebrae,—but was rare in its situation low down behind the oesophagus, and consequently out of reach from the mouth for diagnosis or treatment. As in the case reported by Dr. Turner (loc. cit. supra), due to another cause, there was a complete absence of dysphagia, which is usually a prominent symptom of abscess at the back of the pharynx, although the oesophagus was pressed upon, and through it the trachea, sufficiently to cause signs of obstruction to the respiration. This, however, had lasted for weeks without becoming urgent, and death was due to the attack of pneumonia. A tracheotomy wound would have been a little above the level of the abscess. BILHARZIA HÆMATOBIUM IN WEST AFRICA.