No. 3398.

OCTOBER 13, 1888.

Clinical LectureON

HERNIA INTO THE FORAMEN OFWINSLOW.

Delivered at the London Hospital,

BY FREDERICK TREVES, F.R.C.S.,SURGEON TO, AND LECTURER ON ANATOMY AT, THE LONDON HOSPITAL.

GENTLEMEN,-A patient has lately died in the hospitalwhose case enables me to demonstrate one of the rarestand most remarkable forms of intestinal obstruction-thatknown as hernia into the foramen of Winslow. Those of

you who saw the patient during life will know that no surediagnosis of his trouble was ever made, and that theinterpretation of his symptoms remained until the last amatter of respectful speculation. It will be rememberedalso that in the operating theatre it was shown that thereare still forms of hernia which are beyond the reach of themuch-vaunted surgery of the time. Now that the bodylies in the post-mortem room, the whole surgical history ofthe man is laid bare, and the many doubts and difficultieswhich surrounded the case are made plain.The term " internal hernia," although somewhat reck-

lessly used, is still conveniently applied to such hernia-likeprotrusions of the bowel as lie entirely within the abdominalor thoracic cavities, and yet fulfill the conditions requiredby the common definition of a hernia. Before enumeratingthe varieties of the internal hernia it may be well to notethat some external ruptures may, under certain conditions,assume clinically the characters of the less obvious form.With such may be grouped the smaller varieties of obturator,sciatic, perineal, and lumbar hernice, minute femoral herniseand hernia? in the linea alba in very fat subjects, and thoseruptures about the inguinal reo-ion which are known asinterstitial or inter-parietal. Under the term internalhernia the following varieties may be classified :-

1. Diaphragmatic hernia.-This form of rupture is notvery uncommon. Leichtenstern in his monograph deals with.about 250 examples, of which, however, only twenty-eightwere true herniae-i. e., provided with a proper sac.

2. Anterior retro-peritoneal hernia.-Under this term areincluded the subperitoneal hernise, whose sacs, commencingat or about the internal inguinal ring, have made their wayupwards along the ilio-psoas muscle (hernia intra-iliaca), orinwards towards the pelvis (hernia ante-vesicalis; "hernieintra-pelvienne" of the French).

3. Hernia duodeno-,je,junalis.-This remarkable rupture,named by Sir Astley Cooper the mesenteric hernia, is duein the first instance to the passage of intestine into the fossaduodeno-jejunalis. A large number of examples of thiscondition have been placed on record. I have elsewhere(Hunterian Lectures, 1885) given a full account of theanatomy of the fossa in which the protrusion commences.

4. ltleso-colic AerMZM. —This variety of retro-peritoneal herniawas first described by Sir Astley Cooper. It has no concernwith the duodeno-jejunal fossa. I have endeavoured (in theLectures already referred to) to show that it takes origin inan occasional pouch to be found in the descending meso-colon. It is clinically very nearly allied to the variety justdescribed.

5..Be-o-eeBce /<eMM.&mdash;This term has been applied to pro-trusions of bowel occupying a fossa said to be occasionallyfound behind the caecum, and named by Treitz the subcEecalfossa. Three reputed examples of this hernia have been re-corded, and in two of them strangulation had taken place.The accounts of these cases are a little indistinct.

6. Inter-signzoid hernia.-In this variety the seat of theprotrusion is at the inter-sigmoid fossa, a fossa of consider-able interest to be found in a certain proportion of cases inthe sigmoid meso-colon. Two cases of strangulated herniain this situation have been recorded-one by Lawrence inhis work on Ruptures, and one by Mr. Eve in the ErasmusWilson Lectures delivered in 1884.

7. Hernia into the foramen of TViitslow.-The case aboutwhich I now wish to speak is, I believe, the only example

1T_ nnnc,

of hernia into the foramen of Winslow for which laparotomyhas been performed, and it is perhaps the only case of whichcomplete clinical and pathological data have been forth-coming.John S-, a laundry keeper, aged twenty-six, was ad-

mitted into the hospital on April 17th, 1888, under the careof my colleague, Dr. Stephen Mackenzie, to whom I am in-debted for permission to bring the case before your notice.Previous to admission the man had been under the care ofDr. Robert Ambrose, whose very elaborate notes of theearly symptoms are most valuable. The patient was a goodtype of a well-developed, muscular, and robust man. Hehad " never had a day’s illness in his life," was of steadyhabits, knew nothing of dyspepsia, and never sufferedfrom constipation. He had certainly been free from any intes-tinal trouble previous to the attack which caused his death.On April 9th he ate a very hearty dinner at 3 P.M., con-cluding the meal with a considerable number of periwinkles.At 5 P.M. he was suddenly seized with violent abdominalpain. The pain was like cramp, and was situate about andabove the umbilicus. He was bent double, became faint,and broke out into a cold perspiration. He drank somebrandy, which was retained. The pain was intermittent,the intervals of freedom from pain, however, being veryshort. The abdomen was not tender. The pain persistedall night, and was of such a character that he could not liedown, but spent the night in a chair. Before the morningthe abdomen began to be a little distended, and to feel"light" in the epigastrium. On the 10th he began to vomit,rejecting some milk lie had swallowed. The pain was stillsevere and intermittent, and was still in the same situation.Nothing had passed the rectum since the morning of theprevious day. Dr. Ambrose found the abdomen everywheretympanitic, the meteorism being especially marked in theepigastric region, where, and where only, the abdomenappeared a little swollen. An examination of the rectumand of the cascal region revealed nothing. The patient wassick about ten times during the day. Opium was nowadministered in doses that represented about three grainsof opium powder in twenty-four hours. On the next day(the llth) the pain was much less severe ; but the vomitingcontinued, the patient being sick from ten to fifteen timesin the twenty-four hours. On the 12th the bowels werewell relieved, for the first time since the onset, byan enema. The patient was much easier, and vomitedonce only during the day. The tongue was now coated.The abdomen was more evenly distended, and was tym-panitic everywhere, although the percussion note variedgreatly in degree in different parts. The distension in theregions below the umbilicus was much reduced by theinjection, and the swelling in the epigastrium was therebyrendered more distinct. This swelling occupied more or lessprecisely the epigastric area as anatomically defined, andappeared to be due to the distended stomach and colon. Onthe following day no change was to be noted. The bowelsagain acted after an enema, the patient felt better, andwas only sick twice. Nothing passed the rectum after thisdate, in spite of copious and repeated enemata. Duringthe three succeeding days (the 14th, 15th, and 16th), thepatient’s troubles increased. The pain again became severe,but was no longer intermittent, although it presentedvariations in its intensity. Vomiting occurred from twelveto fifteen times in the twenty-four hours. The epigastricswelling was more distinct, and on the 16th was noticed tobe a little dull on percussion for the first time. There wasno localised abdominal tenderness. As evidence of theman’s general condition, it is noted that on the 15th he in-sisted on leaving his bedroom for some hours, and walkeddownstairs without assistance. On April 17th the patientwas admitted into Dr. Mackenzie’s wards. Before describ-ing his condition when he entered the hospital, I mightmention some general facts in the history of the week thathad intervened since the attack came on. The treatmenthad consisted in rest, in the frequent use of enemata,in fomentations to the abdomen, in a most restricteddiet, and in the daily administration of three grains ofopium. The pain had always been complained of as

about and above the umbilicus. It had at first been inter-mittent, but later had exhibited only variations in in-tensity. It had been of the character of cramp or colic.No specific tenderness had ever been complained of. Duringthe whole of the week the patient had kept the sittingposture, declaring that he was unable to lie down. The

D

702

vomiting had been throughout slight in amount; it was atfirst purely gastric and ultimately intestinal. It was neverfeculent. The sickness gave the patient no relief, and,except on two days (April 13th and 14th), whatever wastaken by the mouth was rejected, although not directly.There had never been hiccough. An almost constanttenesmus had marked the whole progress of the trouble.The urine was normal, was of high specific gravity, andmoderate in amount. The tongue was at first clean, butsoon became coated and flabby, and on April 15th dry andbrown. The pulse throughout had been small and regular,and had varied from 85 to 100. The temperature had beennormal or subnormal, and had averaged 98&deg;. There hadbeen almost complete loss of appetite, with great thirst.Dyspnoea had never been complained of. Intestinal move-ments were at no time visible, nor were borborygmi heard.The skin had been usually moist. The loss of strength hadbeen gradual, and the patient’s intelligence had remainedclear. There had been no discharge from the rectum.When Dr. Mackenzie and I examined the patient, we foundhim in a condition of great prostration, with the pinchedface and sunken eyes of acute abdominal trouble. Thetongue was dry and brown ; the temperature subnormal ;the pulse 98, small and feeble. The patient was now lyingupon the back, with the knees drawn up. Nothing had passedthe rectum for three days. A little brownish fluid with a faintintestinal odour was being vomited about every half-hour.There was still much pain about the umbilicus. Theabdomen was moderately distended, but there was a veryconspicuous bulging of the anterior abdominal wall in theepigastric and hypochondriac regions. The summit of thisswelling was in the median line. In the left hypochondriacdistrict a high resonant note was elicited on percussion,and appeared to indicate a distended stomach. Thewhole of the area defined anatomically as the epigastricwas dull, although a resonant note could be produced ondeep percussion. Elsewhere the abdomen was evenlytympanitic. There was tenderness in the epigastrium, andit was evident that this region was the seat of some peri-tonitis. A rectal examination revealed nothing. The evenswelling above the umbilicus rendered the aspect of theabdomen quite peculiar.Such are the clinical facts of the case. So far as diagnosis

went, it was only possible to say with certainty that therewas an obstruction involving the colon, that this obstructionwas complete, and probably concerned the bowel not farfrom its commencement, and, moreover, that there wassome peritonitis in the epigastric region. There was noevidence to support the diagnosis of intussusception, thesymptoms did not accord with the conception of a mesen-teric or meso-colic (retro-peritoneal) hernia, there wasevidence that the case was not one of volvulus of thesigmoid flexure, and the nearest approach to probabilityappeared to lie in the suggestion of a volvulus of an un-descended caecum. In the light, however, of the presentcase, and the few other examples of hernia into the foramenof Winslow which have been recorded, I believe it possiblethat in future the lesion may possibly be diagnosed duringlife.As the patient’s condition was very urgent, and as both

he and his friends were most anxious that no possible effortto save his life should be spared, Dr. Mackenzie advised anexploratory incision, and in this advice I entirely concurred. The operation was performed on the afternoon ojApril 17th, precisely eight days after the commencement ojthe attack. I opened the abdomen in the median linebelow the umbilicus, and introduced my hand. I firs1sought the caecum, but neither it nor the ascending colorwere to be found. I then passed to the left colon, and founcthat the descending colon, sigmoid flexure, and rectum wereempty and flaccid. I endeavoured to follow the upper en(of the descending colon, but found it impossible to do sowing to the distension of the adjacent coils of small intestine and the presence of a dilated stomach. I now turne(my attention to the small intestine, and soon discoverthat there was no true mesentery. I, however, followeda coil of the bowel until I reached a constricting ring i]the epigastric region through which this bowel passed. Afirst it appeared probable that the ring might be the openin,of the fossa duodeno-jejunalis, and the case one of retroperitoneal hernia. The ring was, however, above thsituation of that fossa, and had no direct relation to thvertebral column. Moreover, the sac of a mesenteric hernicould not be made out, while by following the aorta th

true situation of the duodeno-jejunal fossa could be demon-strated. The orifice through which the coil of intestine passedwas considerably to the right and above the usual situationof the mouth of the sac in meso-colic hernia. By a process ofexclusion, rather than by direct evidence, it became clearthat the constricting ring was the foramen of Winslow ; butthe presence of distended and unaccountable coils ofintestine in the vicinity of the opening rendered thedemonstration of the relations very difficult. The relationwith the stomach could not be defined, and the presence ofgreatly dilated bowel served to confuse its position withreference to the liver. In the tissues in front of the ring anartery, clearly the hepatic, could be felt pulsating. Imanaged to reduce, with but little difficulty, some two orthree feet of small intestine. The reduction, however, ofanother and quite distinct coil which also occupied thering was utterly impossible. It was also impossible to.

enlarge the opening through which the bowel had passed,for even modern abdominal surgery has not proved that thehepatic artery, the portal vein, and the bile duct can bedivided simultaneously with impunity. Further attemptsto relieve the patient had therefore to be abandoned. Thepatient never rallied after the exploratory operation, anddied some six hours after he had been carried back to bed.The condition made evident at the necropsy is known to-

many of you. There was commencing general peritonitis.

FiG. 1.

Aspect of parts on opening the abdomen.

When the abdominal cavity was fully exposed, a coil oflarge intestine, so enormously distended as to befour inches indiameter, was found lying in the left hypochrondriac regionimmediately under the costal cartilages of the left side.Below it the stomach, slightly distended and somewhatdisplaced forwards and to the left, presented itself. Noother viscera were to be seen except the liver and coils ofthe small intestine. No other portion of the colon was inview. (Fig. 1.) Further examination showed that thecsecum, the whole of the ascending colon, and a part of thetransverse colon had passed through the foramen of Winslow,and had become strangulated by the margin of that aperture.The colon, on entering the snare, had passed from right toleft ; the caecum was to the extreme left of the abdominalcavity, and had forced its way through the anterior layerof the gastro-hepatic omentum, so that the vermiformappendix was actually lying on the anterior aspect of the lessercurvature of the stomach close to the oesophagus. (Fig. 2.)The diameter of the strangulated colon measured nearly fiveinches. This part of the bowel was gangrenous in two places.Both patches were limited to the ascending colon; one patch

, was equal in size to a half-crown piece, while the other was: twice as large. The intestine had given way a little in the

703

latter situation, and fsecal matter had found its way intothe lesser cavity of the peritoneum. The colon outside orbeyond the foramen of Winslow turned very sharplyto the left, and was then represented by the dis-

FIG. 2.

Section (diagrammatic) of the abdomen at the level of theforamen of Winslow, showing the hernia in situ.

tended segment of the large intestine already described.as lying above the stomach. (Fig. 3.) On reaching thesplenic flexure, the bowel was so sharply bent upon itself asto be again occluded. This kinking accounted for the greatdilatation of that portion of the transverse colon which laybeyond the seat of strangulation. The descending colon,sigmoid flexure, and rectum were empty and collapsed. Thegreat omentum was found rolled up along the greatercurvature of the stomach. The whole of the small intestinewas distended. Some four or five inches of the terminalparts of the ileum were still found within the hernial cavity.It had passed in with the caecum, but was only partiallystrangulated. The two or three feet of ileum that had beenreduced during the operation were indicated by a purplishdiscolouration as compared with the rest of the intestine.

FIG. 3.

Vertical section (&ugrave;iagrmnmatic) to show the position of theascending and transverse portions of the colon.

At the seat of stricture the colon was in front of the smallintestine. Of the strangulated colon the caecum was thepart that had suffered least. There was a descending meso-colon of moderate length. The colon may be described asbeing very sharply bent upon itself at the foramen ofWinslow. The situation of this acute bending-the seatof the stricture-would correspond to about the centre ofthe transverse colon. The bowel from this point to the topof the cascum was involved in the strangulation. Theremaining (distal) half of the transverse colon was dilatedby reason of the abrupt manner in which the bowel wasagain bent upon itself at the splenic nexure. This portionof the intestine (the distal half of the transverse colon)showed merely the efFec-ts of great tlistension. In otherrespects it was normal. There wa?, of course, no trace of a

hepatic flexure. There was a considerable deo-ree of peri-tonitis in the epigastric area, and a few fresh adhesionsunited the ascending colon to the liver. The liver showedno morbid change of any kind. The stomach was merelydistended. All the other viscera were perfectly normal.It was evident that the caecum was " undescended," andhad led the way through the foramen. The foramen ofWinslow admitted four fingers. The tissues about it appearednormal, and no change could be detected in the structuresoccupying the gastro-hepatic omentum. The gall-bladderwas but moderately full. It was found to be quite impos-sible to i educe the strangulated colon. Traction was main-tained until the peritoneal coat of the bowel began to giveway. Reduction could not be accomplished until thehepatic artery, the portal vein, and the bile duct had beendivided.

It can readily be understood that this variety of hernia isexceedingly rare. Under normal conditions the foramen ofWinslow will only admit one finger, or at most the thumb.It is true that its dimensions vary, but it is quite uncommonto find foramina so large as to admit two fingers. Theopening is placed above the intestinal area, and wouldappear to be ill adapted for the development of a hernia. Theordinary factors in the causation of rupture, moreover, canhardly be considered to have effect in this district. Theloop of intestine nearest to the foramen-the duodenum-isvery fixed, and has, so far as I know, never been foundinvolved in one of these hernie. The hepatic flexure of thelarge intestine and the transverse colon are the only other

FiG. 4.

Diagram of embryonic intestine. A, Meso-gaster. B, Mesentery.c, Meso-colon. D, Meso-rectum. E, Slit left by cutting greatomentum away.

segments of the bowel that may be considered as normallyin near relation to the foramen, yet they are as a rulefirmly secured and not adapted to form the contents of arupture. It may be inferred that, with a normal arrange-ment of the intestines and peritoneum, a rupture of thischaracter is scarcely possible, and I would venture to

express the belief that the hernia into the foramen ofWinslow is only possible when a certain abnormality of theintestine and its mesenteries does exist. The preciseabnormality in question is one that consists in an arrest ofdevelopment, and that represents a reversion to a conditionof intestine that is met with in lower mammals. Thereis a time in the development of the human embryowhen the alimentary canal consists of a simple straighttube suspended in the mesial line by a vertical fold ofperitoneum attached along the posterior abdominal wall.The various portions of the canal become in due coursedifferentiated into stomach, small intestine, csecum, andcolon, and then the upper part of the vertical fold of peri-toneum is called the meso-gaster, the next the mesentery,that below the meso-colon, and the IoNN-est part the meso-rectum. (Fig. 4.) The tube lengthens and forms a great

704

loop, which carries the mesentery with it. This loop has anarrow neck formed by the duodenum above and by whatafterwards becomes the transverse colon below. The looptherefore includes the whole of the small intestine, togetherwith the caecum and the ascending colon. The duodenumand the right extremity of the transverse colon never losetheir primitive relation. They limit the neck of the greatmesenteric fold upon which the bulk of the intestinal canalis slung, and through the strait thus formed the superiormesenteric artery passes. The lower colon retains more orless its original mesial connexion. This elementary con-dition is persistent in many mammals-notably in theant-eater, the sloth, and other edentates. The great intes-tinal loop becomes, as a result of its further development,twisted upon itself. The rotation is to the right; the rightend of the transverse colon is carried in front of the duodenum,and the caecum is brought into the right hypochondrium.At this stage there is still but one great common mesentery,which supports the whole of the lesser intestine, togetherwith the ca cum and ascending colon. This great fold hasits attachment at a point on the posterior parieteswhich corresponds to the original narrow interval betweenthe duodenum and the transverse colon. At such a

stage the caecum is quite free, and has an extensive

mesentery. This condition is the one that holds goodin most of the mammalia below man. It was the con-dition met with in the present case. The csecum andascending colon, together with the jejunum and ileum,were slung by a common mesentery, the attachment ofwhich to the posterior parietes was about the duodenalregion. There was no mesentery with normal attach-ments. In the human subject the so-called "mesentery"

"

that is attached to the posterior parietes from the com-mencement of the jejunum to the ceecal region is aspurious mesentery, and is in no part a relic of the originalprimary vertical median fold. In the present specimen,therefore, a condition was met with that is normal in themajority of animals, and that permitted of the very freestmovement in the csecum and a large segment of the colon.This abnormality I have already described elsewhere.It is only necessary to add that the great omentum isprimarily formed as a pouch from the meso-gaster, andthat it projects to the left. The mouth of this pouchis the foramen of Winslow. In man this foramenis peculiarly small. In many animals it cannot besaid to exist. In the great kangaroo, for example, thegreat omentum is merely a large shallow pouch, the widestpart of which is its mouth. Even in animals with

peculiarly large great omenta, as in some of the carnivora,the foramen of Winslow is relatively much larger than inman. In the present case it is reasonable to assume thatwith the abnormal disposition of the intestinal canal wasassociated an abnormally large foramen of Winslow. Butfor this abnormality, this reversion to a lower anatomica]type, it is a question whether the lesion encountered in th{present case could have occurred.

In conclusion, I must speak of the other known example;of this peculiar rupture. I believe I am correct in statingthat no specimen of this condition exists in any metropolitaimuseum. With regard to recorded examples, I can onlfind accounts of four cases.

1. Rokitansky states: "We once found a large portion osmall intestine strangulated in the fissure of Winslow." Nother details are given.

2. Blandin2 gives a case, the circumstances of which ar<

more fully described by Jobert. 3 The patient was a malwho was admitted into hospital with acute peritonitis, owhich he soon died. Nearly the whole of the small intestinhad passed through the foramen of Winslow. The gut wastrangulated and a portion was gangrenous. Some part cthe intestine had escaped from the lesser sac of the peritoneum through a rent in the transverse meso-colon.

3. Majoli4 cites the following. An emaciated man, thsubject during the greater part of his life of chronic corstipation, presented a persistent bulging of the antericabdominal wall in the epigastric region somewhat more tthe right than to the left. A painful, rounded tumouidull on percussion, was readily defined in this situatioiSymptoms of obstruction of the bowel were present. Th

diagnoses of faecal accumulation or of colic intussusceptio1 Handbuch der path. Anat., 1842, Bd. iii., p. 136.

2 Trait&eacute; d’Anat. topograph., 1834, p. 467.3 Trait&eacute; des Malad. chirurg. du Canal intestinal, p. 522.

4 Rivista clin. di Bologna, July, 1884.

were proposed. Enemata were employed, and doses ofmetallic mercury were given, but without effect. The mandied fifteen days after the onset of the symptoms. Thenecropsy revealed a loop of the transverse colon strangulatedin the foramen of Winslow. The bowel was gangrenous.

4. Mr. J. Elliot Square, of Plymouth,5 describes the caseof a man aged twenty-three who was seized with suddenand violent abdominal pain in the epigastrium shortly after2b very hearty meal. He presented the symptoms ofintestinal obstruction. The pain was intense over andabout the xiphoid cartilage ; the epigastrium was tender,and the umbilical region of the abdomen unduly prominent.The patient died three days and seventeen hours after thecommencement of the attack. At the post-mortem amoderate degree of peritonitis was found, and eight inchesof the ileum (two feet from the caecum) were found strangu-lated in the foramen of Winslow. The foramen admittedtwo fingers. The gut was gangrenous. The csecum is statedto have been " freely movable, and to have possessed ameso-caecum.

It is probable that in this case, and possibly in the casedescribed by Majoli, such an abnormality of the intestineexisted as has been already discussed. It will be noticedthat in the more fully reported cases stress is laid uponthe epigastric pain, upon the presence of a swelling inthat region, and upon the existence of dulness over theswollen district. In no instance does there appear to have ebeen any hepatic trouble or any jaundice.

DAVOS AS A HEALTH RESORT.BY T. CLIFFORD ALLBUTT, M.D., LL.D., F.R.S.,

CONSULTING PHYSICIAN, LEEDS GENERAL INFIRMARY, ETC.

TEN years have elapsed since I first wrote on the suit-

ability of Davos as a health resort, and reports of mysubsequent visits and of my experience of cases of phthisistreated at that place appeared in THE LANCET in the years1879 and 1880. In 1878 few English invalids had foundtheir way to the Grisons, and but two or three physiciansin England had published any information on the subject.My own knowledge of Davos was first derived from Germansources, from some references thereto by Dr. HermannWeber, and indirectly from the friends of one of the firstEnglishmen cured of phthisis in the Engadine, though notat Davos.1 After my first and subsequent reports, manyEnglish physicians visited Davos, notably Dr. TheodoreWilliams ; and the English colony increased rapidly there,and grew from a handful to scores and hundreds in so short atime that I thought Davos might well be left to its owndevelopment and to the practical demonstration of its ownvirtues. The kind of cases to be sent thither, the kind ofrecoveries to be hoped for, and the mode of life in the placewere already so well known that a few years of silenceseemed not unfitting. In the meanwhile, my visits andmy inquiries have been directed to other health resorts, andI have sent many patients to other places.This summer I have again visited Davos, with the added

interest of seven years’ further experience both of thatand of other resorts, and with the hope of finding in Davossuch improvements of its natural advantages as the publichave a right to expect. This hope, I may say at once, hasbeen fully justified by the changes I have witnessed. Thesudden influx of visitors to the English quarter of Davoshas been so great and so constantly increasing that, if thehotel-keepers and the inhabitants in general had not beenmen of spirit and resource, the place would have beenthrown back for a generation. English visitors comeabroad calling for a high standard of accommodation, foodand sanitation ; and, had their habits been offended inthese respects, their chances of recovery would have been

, less, and their reports to their friends would have been! hostile to the place. At a heavy cost, however, improved-ments both of a smaller and larger kind have beencarried out. I would especially refer to the canalia-

! tion of the river Landwasser, a large and costly work of

5 Brit. Med. Jour., vol. i. 1886, p. 1163.1 In a small volume entitled "A Season at St. Moritz" (Longmans.

1870), Dr. Burney Yeo published some observations and experiences ofphthisis treated in the High Alps, which, however, then seemed to himrather discouraging.