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intestine. This simulation of ascites by intestinal dilatationis described by Nothnagel who states that ascites can be

excluded by digital succussion over the dull area, which

produces a splashing sound not found in ascites. When M.

Mathieu first observed the dulness and splashing sound

about ten years ago he was not acquainted with any of thewriting on the subject, and his problem was not to

distinguish the condition from ascites but from gastricstasis. In two cases of stenosis of the upper third of the

jejunum the fluid accumulated in a coil immediately belowthe stomach, and a splashing sound was heard immediatelybelow the umbilicus. But the passage of the stomach-tube

showed that the stomach was empty. M. Mathieu was

thus led to consider the I I syndrome " of intestinal

splashing simulating the splashing of extensive dilata-

tion of the stomach and dulness of the dependentpart of the abdomen simulating ascites as almost patho-gnomonic of slowly progressive stenosis of the intestine.The following is an example. A woman, aged 39 years,came under observation. She had suffered from dyspepsiasince the age of 20 years. Six months previously she beganto suffer from abdominal pains followed by diarrhoea. She

passed several glairy stools daily, sometimes containingmembranes. Crises of abdominal pain occurred every threeor four days and were sometimes followed by vomiting.Examination showed distension of the abdomen, most markedon the right side. Dilated coils of intestine could be im-

perfectly observed. The crises became more frequentand more painful. They began by severe rigors and

painful spasms in the lower abdomen followed bygurgling sounds. By digital succussion a splashingsound could be produced, and by total succussion a wave-like sound exactly like that of a greatly dilated stomach.

When the patient lay on the left side dulness was found inthe corresponding flank and iliac fossa. When she lay on theright side these parts became resonant and dulness appearedon the opposite side, but not to the same extent as on theleft side ; in the most dependent part was a resonant zone,above which dulness was well marked. It seemed that the

cascum was dilated and full of gas and that fluid in the

small intestine was displaced. Two days later peristalsis ofthe small intestine was distinctly seen. Laparotomy showedthat the cascum was a little dilated and red. At the junctionof the inferior fourth with the superior three-fourths of theascending colon was a hard swelling divided into two partsby a fibrous band. Evidently a growth had produced stric-ture of the large intestine. An artificial anus was made in

the csecum. From this a jet of fasces escaped at eachdressing on the three days after the operation.

THE PUBLIC HEALTH OF MANCHESTER.

THE report of Dr. J. Niven for 1907 shows that the health ofManchester is fairly satisfactory but it might and, it is hoped,will be better. The death-rate-17 9-was practically thesame as in 1905, and though higher than it should be, it is agreat improvement on that of some years ago when it was25, 27, or 28, or occasionally even more, per 1000. The cool

summer, which was generally looked on as unfriendly, didManchester one good service in reducing the summer

diarrhoea which levies so heavy a toll on infant life. Theinfantile death-rate was the lowest yet reached. The birth-rate was also the lowest Manchester has recorded, except in1901, when cases of arsenical poisoning were so numerous.Dr. Niven thinks that school outbreaks of diphtheriaare probably due to overlooked persistent cases. For con-

trolling measles he says that more powers and increasedstaffs are necessary. As to enteric fever, he considers thatthere is some source of the disease in autumn as yet undis-covered, and draws attention to the remarkable persistence

of infection in some cases. It is a satisfaction to know thatboth enteric fever and tuberculosis show a declining death-rate. Reverting to the low birth-rate, it is curious to note

that it is lowest in the well-to-do districts and highest in themost poverty-stricken. The Ancoats and St. George’s town-ships, holding the highest places among the latter, have erespectively a birth-rate of 34-12 and 31 - 83, with also thehigh death-rate of 25-33 and 24,24. On the other hand,Crumpsall, Moss Side, and Withington have the respectivebirth-rates of 20 - 28, 20 - 69, and 20 - 62, while the death-ratesin the same order stand at 12 - 27, 13 - 95, and 9-54. There e

is a sudden drop in the birth-rate from 32-30 in Hulme, thelast in the list of the poor districts, to 20 - 28 in Crumpsall.In the Jewish district of Cheetham the birth-rate is 28-63and the death-rate only 11 - 58. It is evident, therefore,that it is the artisan population and the Jews who are

increasing most rapidly in and around Manchester.

EXCISION OF THE TONSIL FOR A MALIGNANTGROWTH.

THE difficulties of the removal of a tonsil which has)ecome the seat of a malignant growth are very great, partly)ecause of the depth at which it is situated and the nearness)f some important structures, but mainly on account of the’act that the lymphatic glands are very early and widelydfected ; and this is so not only in the case of carcinomata:)ut also in the most common form of malignant growth ofjhe tonsil, the round-cell sarcoma. It follows from this

apid involvement of the glands that if any attempt is to besuccessful it must be made before the glands have becomenuch affected. Several methods of operating have beenlevised, and the method may be varied according to thesection of the glands. In the present issue of

rHE LANCET Mr. Harold Upcott of Hull has described

very clearly and fully the mode of operating which

1e has adopted in two cases. The main points in

jhe method which he has employed are these. He placeshe patient in an inclined position with the head up in

)rder to diminish the venous hoemorrhage. He controlsirterial bleeding by a temporary occlusion of the external or)f the common carotid artery by means of a clamp. He per-forms a tracheotomy either before commencing the operationtself or after the cervical glands have been removed. The

pharynx is opened from the side after the mandible has beenlivided, and when the tonsillar growth has been excised he}loses the pharyngeal wound and sutures the jaw. In order

;o prevent septic infection of the cervical wound while theionsil is being removed he packs it with gauze impregnatedvith vaseline, and this appears to us to be a useful device.We have mentioned the chief points in Mr. Upcott’speration, but his paper is well worthy of study for

ihe many details to which he refers. The question ofiemporary or permanent occlusion of the external carotid

artery is difficult. The chief objection to ligation is the

iability to secondary haemorrhage if the wound becomes

nfected, while temporary occlusion is free from this risk. Itias been suggested by Sir W. Watson Cheyne that the arterynight be tied a week before the operation, and in one case invhich this was done by him there was no more bleeding’rom the deeper parts than if the artery had just been tied,mt this method would require a week’s delay in the opera-ion. It appears to us to be a procedure worthy of employ-nent in suitable cases, but temporary occlusion is

mdoubtedly of very great value. One common cause of

leath after removal of a malignant tonsil is septic pneu-nonia, and the most important factor in the prevention of5his complication, especially in hospital patients, is the pre-

Liminary cleansing of the month by the removal of stumpyind carious teeth and by the employment of a tooth-brush