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picture which he draws is of the most striking characterand it falls to the lot of but few of us to see suchcases during life. The combination of vomiting, choking,inanition, and obvious hunger in a newly born infant suchas he describes is apparently produced as the result of

pharyngeal or oesophageal malformation and nothing eise.Curious cases of choking induced by the swallowing of fluidshave been described as occurring in the adult but here thecauses are of different and diverse nature. The late Dr. J. S.Bristowe discusses such cases in his volume on Diseases ofthe Nervous System under the heading, "A Peculiar Form ofChoking caused mainly by Swallowing Fluids." He also

mentions an ingenious method of discovering the site ofan abnormal communication between the air and food

passages. The method consists in passing an cesophagealtube into the stomach and administering fluid throughit whilst it is gradually withdrawn until the point isreached at which choking occurs. It is quite obvious,however, that in the case of the infants above men-

tioned the choking is due to overflow of the contents ofthe pouch above the stricture into the rima glottidis, theabnormal tracheal communication being below and not abovethe site of occlusion. Mr. Thomas indicates, and we thinkvery properly, gastrostomy as the proper operation, combinedwith rectal feeding. The difficulties of any direct operationon the oesophagus must necessarily be almost insuperableand, moreover, in some instances the site of the fistulais as low down as the main bronchus. Any inter-ference with the trachea at once increases the risks of

broncho-pneumonia, risks which, from the nature of the

choking, are already very great. These malformations havebeen extensively discussed by pathologists. They are men-tioned and illustrated by Mr. J. Bland-Sutton in his work onTumours and are discussed in a masterly manner by Mr.S. G. Shattook in the forty-first volume of the Transactionsof the Pathological Society of London. Mr. Shattock’s articlewill well repay perusal by those interested in the subject.He ascribes the malformations to the mechanical influence ofthe lung outgrowth from the primitive intestinal tube andbrings forward considerable evidence in support of his con-tentions. Incidentally also he deals with certain malforma-tions of the aorta which may have a somewhat similar

mechanical origin. -

TICK FEVER.

THE Treasury Department has issued from the HygienicLaboratory Bulletin No. 14, by Dr. John F. Anderson, pastassistant surgeon and assistant director, Hygienic Laboratory,United States Public Health and Marine Hospital Service

(Washington, 1903). The subject of the bulletin is SpottedFever (tick fever) of the Rocky Mountains. The diseasehas been known in the valley of the Bitter Root River inWestern Montana for about 20 years and is sharply localisedon the west bank of the river. It is also known to occur in

Idaho, Nevada, Wyoming, and in a mild form in Oregon,but does not prevail south of 400 or north of 47°. It prevailsat an average elevation of about 3000 to 4000 feet, exclu-sively in the spring and early summer, and among personswho follow occupations that cause exposure to the bites

of ticks. To Wilson and Chowning belongs the creditof discovering an intracorpuscular parasite which is

very probably the cause of the fever. Dr. Andersonsaw the parasites under three forms : (1) the most

common was a single ovoid body, refractile, and ableto project pseudopodia ; (2) a larger form, larger at oneend and showing a dark granular spot, also amoeboid ;and (3) a form arranged in pairs, distinctly pyriform,with the smaller ends approaching. On a study of the casesof tick fever it was always found that there was a history oftick bites about one week before the onset. The ticks which,a. e apparently necessary for the transmission of the disease

belong to the genus dermacentor. The symptoms whichfollow the incubation of about seven days are for a few dayschilly sensations, malaise, and nausea ; finally there is a

distinct chill and the patient takes to bed. There are pains inthe head and back ; soreness of the muscles and bones ; con-stipation ; tongue with heavy white coat, red edge and tip ;conjunctivas congested, becoming yellowish ; urine scanty,with albumin and a few casts ; slight bronchitis after a fewdays ; and bleeding of the nose, sometimes quite severe, isalways present. Before the distinct chill there is littleor no fever in the morning, with a slight rise of tem-

perature in the afternoon. After the chill there is an

abrupt rise and then the fever gradually increases in the

evening, with a slight morning remission. The maximumis usually reached on from the eighth to the twelfth day.The pulse-rate appears out of all proportion to the tem-

perature, usually running from 110 to 140. Red bloodcounts show a progressive decrease in red cells. Thewhite blood corpuscles are increased in number, a mostinteresting feature being an increase of the mononuclears.The eruption appears usually on the third day, first on

the wrists and ankles, then on the arms, legs. forehead,back, chest, and, last and least, on the abdomen. Atfirst the spots are bright red ; they are macular and

in size from that of a pin-point to that of a split pea.From about the sixth to the tenth day of the disease theyfail to disappear on pressure and are distinctly petechialin character. When convalescence is advanced desquama-tion extends over the entire body. Of 121 cases whichoccurred in or near the Bitter Root Valley 84 patientsdied. Since the discovery of the parasite Dr. Wilson andDr. Anderson suggested the use of quinine in large doses,preferably hypodermically. In five cases in which it was

used recovery took place. Quinine bimuriate, one gramme,should be given every six hours hypodermically. The heart’s

power should be supported with strychnine and whisky.The patient should be encouraged to drink large quantities ofwater to flush out the kidneys. For the fever warm spongebaths or packs are useful and refreshing. Milk, broths,lightly boiled eggs, and soft toast may be allowed. As soonas a person is bitten by a tick the insect should be removedand the place cauterised with 95 per cent. carbolic acid.

By applying ammonia, turpentine, kerosene, or carbolisedvaseline the tick can usually be detached without trouble.

HOMES FOR EPILEPTIC PATIENTS IN POOR

CIRCUMSTANCES.

WE frequently receive inquiries from medical men whoare endeavouring to find a home for some epileptic patient inpoor circumstances. At present there is very limited pro-vision for these distressing cases, but it may be convenientfor our readers to mention some ways of dealing with them.The patients fall into two categories, those without mental

i impairment and those in whom there is temporary orpermanent mental derangement. For the sane epileptics-there are several excellent institutions.

1. The Colony for Epileptics at Chalfont, where provision is made forover 100 adult epileptics, both male and female, and also for children.Arrangements are made for educating the children and for employingthe adults in market-gardening, carpentering, laundry work, and otheruseful industrial occupations. At present only working class patientsare taken, for whom a payment of 108. per week is required, but areduction is made to boards of guardians. The colony is managed bythe National Society for the Employment of Epileptics. whose officeis at 12, Buckingham-street, Strand. All applications should be madeto the secretary, Mr. G. Penn Gaskell.

2. The Home for Epileptics, Maghull, near Liverpool. This homehas been open for 14 years and at the end of the year had 174 inmates.Like the Chalfont Colony the inmates are lodged in several homes ona farm and they are chiefly employed in out-of-door pursuits, suchas market-gardening. At Maghull provision is made not only forworking-class but also for second-class patients, and there is alsolimited private accommodation for first-class patients. The rates ofpayment are : working-class patients, 78 6d. ; second-class patients,f:1 ls.; and first-class patients from .E2 28 upwards, according toaccommodation. Application has to be made to the honorary secretary,