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NECK.

Radical Operation for Diverticula of the Conjointly with the account of the radical operation performed by Bruns for the cure of so rare an affection as diverticulum of the esophagus, the author records and analyzes twenty-two reported cases of radical cure. The his tory of the operated case is that of a female, aged fifty-seven years, who had noticed since youth a smacking noise attending all deglutition, but only the progressive interference with swallow ing during the past seven years impelled her to seek relief. The rapid swallowing of water or finely divided food caused a bulging at the anterior margin of the sternomastoid. Upon bending for ward or after violent attacks of coughing, all fluid and food were brought up again. A sound passed into the esophagus entered the diverticulum, and the button could be palpated just behind an existing struma.

An incision was made along the anterior margin of the sterno mastoid, exposing the esophagus. At the level of the cricoid cartilage a saccular enlargement of the esophagus was encoun tered. After isolation of this latter, a purse-string suture was applied and the redundancy ablated ; to still further guard against leakage, a Lembert suture was applied. The lower angle of the wound was tamponed with gauze and a drainage tube inserted. During four days following no food was given per os. On the seventh day change of dressing, on the ninth day all drainage gauze removed, and within four months the closure of the wound was complete. At no time was there any leakage of the ingested food.

As to the other twenty-two cases, differences existed prin cipally regarding the technique. While Kocher advocates a transverse incision, most of the others stand for a vertical inci sion. Only three cases are noted with primary closure of the esophagus wound. The failure being due to the want of care to apply sutures in the same fashion as for intestinal work, and in addition the hastiness to give food by mouth. Since five deaths (25 per cent.) occurred among these twenty-two operated cases, the author passes in review some worthy methods other than operative which effected a cure. Thus by lying on the side oppo site to the diverticulum, mere gravity, it is claimed, will divert the food from the diverticulum, and this, if sufficiently long persisted in, will cause an atrophy of the sac. With the same purpose in mind repeated use of the sound may accomplish a cure. Faradiza tion of the sac has also been successfully tried. In three instances where inanition set in gastrostomy had to be resorted to. In opposition to removal of the sac, invagination has been proposed and performed with good result. In conclusion, the author com ments on the apparent reluctance to the performance of the radical operation, which he accounts for chiefly on the ground of failure to recognize the condition, and then the invariable at tendance of cellulitis, in the pre-antiseptic days, which deterred operators from the performance of this capital procedure. Though a mortality of 25 per cent. is associated with this opera tion, the eventual fate of starvation and possible contingency of carcinomatous degeneration justify operative interference, which, with the increased experience from the frequency of performance, must needs reduce this mortality considerably. Beitriige zur klinischen Chirurgie, Band xxvii, Schluss, Heft 3.

food, esophagus, cure, diverticulum and radical