786

cases of " fever" and the 2 deaths from diphtheria were alsoreturned in Glasgow. The deaths referred to diseases ofthe respiratory organs in these towns, which had declinedfrom 82 to 53 in the preceding three weeks, rose againlast week to 80, but were 15 below the number in thecorresponding week of last year. The causes of 38, or

nearly 8 per cent., of the deaths in the eight towns last weekwere not certified.

-

HEALTH OF DUBLIN.

The death-rate in Dublin, which had been 22’1 and 21-0per 1000 in the preceding two weeks, rose again to 27’5during the week ending Sept. 26bh, a higher rate than in anyweek since the beginning of April last. During the pasttwelve weeks of the current quarter the death-rate in theCity averaged 20’6 per 1000, the rate for the same periodbeing 17-6 in London and 16-0 in Edinburgh. The 188deaths in Dublin during the week under notice showed an’increase of 44 upon the number in the preceding week, andincluded 20 which were referred to diarrhoea, 5 to

whooping-cough, 3 to "fever," and not one either to

small-pox, measles, scarlet fever, or diphtheria. In all,’28 deaths resulted from these principal zymotic diseases,equal to an annual rate of 4-1 per 1000, the zymoticdeath-rate during the same period being 2’5 in Londonand 2’4 in Edinburgh. The fatal cases of diarrhoea, whichhad been 14 in each of the preceding two weeks, rose to 20last week. The 5 deaths referred to whooping-coughshowed a further increase upon the numbers recorded inrecent weeks. The fatal cases of "fever," which had been3 and 4 in the preceding two weeks, were 3 last week. The188 deaths in Dublin included 60 of infants under one yearof age, and 36 of persons aged upwards of sixty years; thedeaths both of infants and of elderly persons showed amarked increase upon the numbers recorded in the preceding’week. Four inquest cases and 7 deaths from violencewere registered; and 54, or more than a fourth, of thedeaths occurred in public institutions. The causes of 25,or more than 13 per cent., of the deaths in the city werenot certified.

____________

THE SERVICES.

BRIGADE-SURGEON LIEUTENANT- COLONEL R. COLLINShas assumed’ the duties of Principal Medical Officer,Woolwich District, and taken over command of the 9thDivision Medical Staff Corps from Surgeon-Colonel F. W.Wade, who has proceeded on leave prior to embarkaticnfor India.ARMY MEDICAL STAFF.-Surgeon-Colonel S. A. Lith-

gow, MD., C.B., D.S.O., is about to obtain his pro-motion from the 16th ult., vice Surgeon-Major-GeneralG. M. Slaughter, placed on retired pay (dated Sept. 26th,1891). Brigade Surgeon T. O’Farrell has taken over theduties of Principal Medical Officer of the British troopsin Egypt.-The following Surgeon-Majors complete nextweek twenty years’ service, and will accordingly becomeentitled to promotion to the rank of Surgeon Lieutenant-Colonel: - R. V. Ash, M, B, Brighton; C. E. Dwyer,Bengal; F. E Barrow, Hongkong; R. Blood, M.D., Win-chester; H. J. W. Barrow. Bombay; W. P. Bridges, Park-hurst ; R. Drury, M.D., Curragh; and W. C. Grant, M.B.,.Bengal.ARMY MEDICAL SCHOOL.-Brigade Surgeon Lieutenant-

Colonel Charles Henry Young Goodwin, Medical Staff, tobe Professor of Clinical and Military Surgery, vice Surgeon-General Sir Thomas Longmore, Knt., F.R C.S. Eng., C.B.,Q.HS., half-pay, who resigns that appointment (datedOct. 1st, 1891).NAVAL MEDICAL SERVICE. — The following appoint-

ments have been made at the Admiralty: -SurgeonsOctavius W. Andrews, M.B , to the Cordelia, and ThomasC. Meikle, M.B., to the Hecla (both dated Sept. 29th,1891).VOLUNTEER CoRPs.-Artillery: TheTynemouth(Western

Division, Royal Artillery): Acting Surgeon John FrancisHaswell, M.B , to be Surgeon (dated Sept. 26th, 1891).-1st West Riding of Yorkshire (Western Division, RoyalArtillery): Acting Surgeon Sydney Rumboll to be Sur-geon (dated Sept. 26th, 1891). - Royal Engineers (Sub-marine Miners): The Tees Division: Acting Surgeon Wm.Jones Williams, M.D., to be Surgeon (dated Sept. 26th,1891).-Rifle: 2nd Volunteer Battalion, tbeNorthumberland Fusiliers: Acting Surgeon Hugh Frazer Hurst to be Surgeon Il{.dated Sept. 26th,1891).

Correspondence.

"RECURRENCE OF SYMPTOMS AFTERGASTRO-ENTEROSTOMY."

" Audi alteram partem."

To the Editors of THE LANCET.

SIRS,-I hope you will spare me a little of vour space toreply to Mr. Jessett’s letter in your issue of Saturday last.The subject is one of such importance and seriousness that Ithink it should be fully discussed and every possible lightthrown upon it. I feel, too, and every surgeon must feel,that what Mr. Jessett says in such a matter is worthyof most careful consideration, and as I differ from him inone or two matters, I think it all the more important to statemy reasons for differing. I held, and still hold, that therecurrence of symptoms was, in my case, most prnbably dueto closure of the artificial opening, and more probably fromcicatricial contraction than from extension of the disease,and must insist in support of this that we have one well-authenticated and carefully reported case (Stansfield’s),while I do not know of any case in which closure has beenproved to be due to malignant extension, and certainly inone (one of Kilner-Clarke’s) extension around the orifice didoccur without closing it. I am not now able to look up all thecases published in which symptoms have recurred afterseveral weeks or months, and in which the cause has beenascertained by post mortem examination. Of this, though,I am certain, that they are very few ; so that even thoughMr. Stansfield’s case stands alone, it still forms a consider.able percentage of the whole number. Again, Mr. Jessetthas himself acknowledged that this cicatricial contractionis a possible danger, and attached sufficient importanceto it that he has even suggested means by whichthe ordinary operation may be modified so as tomake the risk "probably nil." I, however, must paychief attention to Mr. Jessett’s main suggestion-i.e.,that the contraction occurred at the opening made in theperitoneal layers of the transverse meso-colon and greatomentum. This, of course, is one of the many possibilitiesthat would come into one’s mind; but I dismissed it at oncefrom several considerations which to my mind render ithighly improbable, if not quite impossible. I think thatfrom general considerations it is highly improbable that awide peritoneal tear, healing as it did by first intention,would give rise to cicatricial contraction. My experienceof peritoneal healing is quite against this. Besides, wemust not be special pleaders. What applies to one openingapplies to the other. If we get contraction here, why notaround the gastro enterostomy opening ? Both are sur-

rounded by peritoneal adhesions, and the latter would notall heal by first intention. In fact, we are asked to expectmore cicatricial contraction in the primary union of two thin ’serous layers than in the healing, partially by granulation,of two mucous surfaces. The idea of kinking occurring atthis site is much more tenable, only for my part I thinkkinking would be sudden, and the symptoms in one casetook three weeks to develop. But all these considera-tions apart, there are facts which almost demonstrate theinaccuracy of this suggestion. If the diagram in my noteslbe looked at, one can clearly see that we may divide theintestine into three parts: (1) Extending from the obstructedpylorus to the peritoneal opening, and consisting of allthe duodenum and part of the jejunum; (2) the loopof jejunum drawn through the peritoneal opening; and(3) the rest of the intestine to the anus. Mr. Jessettwill recollect that the biliary and pancreatic ducts openinto part (1). Now, supposing then that there is completeobstruction at the junction of (1) and (2), the patient wouldpractically have obstructive jaundice, but her motionswere always well coloured, and she never developed anyicteric tinge. Suppose, though, that the obstruction wasnot complete, and allowed bile to pass into section (2);and even allow that the stricture at the junction of (2) and(3), though sufficiently tight to prevent the pa,ssage ofchyme, allowed enough biliary matter to pass to stain thefaeces. Supposing all this, let us consider the condition ofsection (2) ; it would communicate with the stomach by thewide artiticial opening, and with the intestine (3) by a narrowpassage. Under these circumstances, would not the bile

1 THE LANCET, Sept. 19th, p 668.