great depression of spirits; no appetite whatever, and even a horror of food. The tongue on the 10th day of this relapse cleaned off rapidly, looking like a piece of raw beef, but soft and moist, never hard or dry. This intense sleepiness continued for about ten days after the fever broke. The emaciation was very great for the first few days, no tympanitis throughout; no tenderness or gurgling in the right iliac region, but at the time the tongue cleans, a general soreness all over the abdomen (this, however, may have been caused by the cough, which has been quite bad). He slept without having to take anything to produce sleep. This case went through the variations of a continued fever, and was discharged August 22d, 1888, though still very feeble and just able to sit up for a short time each day. My treatment throughout was expectant, using principally stimulants, turpentine and nourishing liquid food-principally milk.

CASE 2. Was called to see Mrs. P., January 9th, 1889. She had been complaining for three days; found her sitting up, though very much depressed, no fever but severe headache, tongue coated with a thin white coat. No fever on the 10th, but had not rested well for several nights (all of these cases complain of horrid dreams). The next day found her with a temperature, 105; pulse, 120; tongue coated, severe headache, pains in all the limbs, as she expressed it, as if they would break in two. Treated her expectantly, had to give opiates to control nervousness and headache, especially at night, bowels very much constipated; this fever ran twelve days, then subsided, had no fever for ten days; was called to see her again, found that she had taken cold, and had quite a severe bronchitis; this second fever ran twenty-one days. The tenth day, the tongue cleaned off in one night, was bright red and glazed the next morning, though soft and moist. The abdomen tympanitic and tender upon pressure, though not especially in the right

iliac region, no gurgling. On the fifteenth day of this relapse, there was some diarrhoea, lasting three days, though easily controlled. The convalescence has been extremely slow (and she is very weak at this time), and accompanied by severe pains in the lower limbs, and more especially the feet. This has been the case with most of the cases that I have seen.

I have found no definite line of treatment satisfactory, but treat all of them expectantly. In most cases, stimulants, turpentine, and nourishing liquid diet, especially milk, and perferably butter milk. (If they eat any solid food too early, it always produces a relapse). Opium is indispensible, nothing takes its place. Bromides, chloral, etc., seem to have a deleterious effect. The cough can not be controlled by the ordinary expectorants, but has to be controlled by acting on the stomach.

Now I call this Gastric Fever, distinctive from Typhoid, Bilious, or any of the fevers that we usually have through this section. It is not very fatal. I consider it a low form of inflammation or irritation of the stomach, (probably a GastroHepatic trouble), and will run its course in spite of all treatment. In some cases it comes on suddenly (in fact in the majority of cases) with a chill, and in a few hours quite a high fever, 103 or 104, and each day thereafter the fever declines slowly until the tenth or fourteenth day there is entire cessation of the fever. Relapses are frequently, with the slightest cause, and frequently without any perceptible cause. I consider quinia and calomel as extremely dangerous in this fever. Quinia increasing the disposition to head trouble, and there is in a great many cases spontaneous salivation, but calomel is almost certain to salivate.

PARING AND SUTURE CLAMP FORCEPS.

(Read before the Atlanta Society of Medicine, January 5th, 1889.)

BY EDMOND V. JOYE, M. D., ATLANTA, GA.

Being present, some years ago, at an operation for simple vesico-vaginal, fistula, I noticed a great deal of time was consumed in taking up the vaginal mucous membrane, with the barbed hook, or tissue forceps, for the purpose of paring the edges of the fistula. Thinking this could be overcome by an instrument which combined the hook and elevator, thus raising the tissue and holding it in situ, I accordingly caused to be made the following instrument, which seems to meet all indications, and renders the operation comparatively simple and easy, reducing the time of its performance more than twothirds. The instrument consists of two blades, each eleven (11) inches long, which are crossed and locked similarly to the Hodge Forceps." Two inches of the extremities of the blades are made round, into which are inserted five (5) hooks, equi-distant. The hooks are sharp and small at the free end, and thick where they enter the blade, (so made to avoid tearing out easily.) Shanks four (4) inches long, containing the screw lock of the "Hodge Forceps." The handles are five (5) inches long, slightly curved downwards, (in order to be out of the way of operator,) with ratchet to hold and fix the blades in any desired position, either extended or brought together. The whole instrument is made as light as consistent with strength and durability.

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The operation for simple vesico-vaginal fistula is thus performed: The patient is placed in the position recommended by

Dr. J. Marion Sims for such operation, viz: "Lying on the left side, with the thighs drawn up, or flexed, the right one a little higher than the left. Left arm thrown behind across the back, and the chest rotated forward, bringing the sternum nearly in contact with the table, while the spine is fully extended, with the head resting on left parietal bone." Chloroform is administered, Dr. Sims' duck-bill speculum introduced, an assistant holds up the right side of the nates.

The instrument being unlocked, the left hand blade is passed in the vagina, and hooked into the mucous tissue on the right side of the fistula, (not too near the edge,) and rotated from left to right, thus bringing the lock up with the points of the hooks looking toward the right side; and as the screw of the lock is upon the top of the blade, the handle is held down and the right hand blade is then passed in over the other, and the hooks hooked into the left side of the fistula, rotated from right to left and brought above and across the left hand blade. The blades are now locked, the handles brought together and fixed by the ratchet. The fistula is thus firmly held, with its edges everted. The next step is to pare the edges, which is best done with Dr. Emmet's straight and curved scissors. This over, pass the needles, armed with silver wire, one in front of first hook, then one between each hook, and lastly, one on the outside of the last hook. Twist up the sutures and cut them off; unlock the blades, rotate them in the opposite direction from that when passed in, and hooked, thus relieving the hooks, withdraw the blades, and the operation is complete.

The advantages gained are these: 1st. By fixing the fistula with the instrument, you are enabled to pare the edges at one stroke of the scissors, whereas, with the barbed hook or tissue forceps, you are compelled to do a great deal of nicking. 2d. The blades constricting the pared edges of the fistula, furnish considerable support for the passage of the needle, which can