washed out with mercuric solution 1: 2000, a drainage-tube introduced, and the usual dressing and a posterior splint were applied.

The cases all made good recoveries, with functionally perfect joints. Mr. Owen's remarks seem worth reproducing in full :

"Twenty years ago three reports like the preceding would have attracted considerable attention. A few years later they might have been regarded with something approaching suspicion, unless they had occurred in an atmosphere of carbolic spray and under a shield of gauze and 'hat-lining.' In the last decade of the nineteenth century they can hope for nothing better than a quiet, unostentatious burial in the medical press. Three knee-joints were opened, two by surgically clean scalpels, and one by an unclean nail. If the nail had been as clean as the scalpels, probably neither constitutional nor local disturbance would have followed the injury, and it seems more than likely that the man escaped acute septic arthritis by having his joint washed out on the first approach of danger. A clean incision into a joint can do no harm. An incision into, or puncture of a joint, made by anything else than a 'clean' knife, should be regarded with grave suspicion. If the surgeon do not deem it expedient there and then to open and wash out the synovial capsule, he should, at any rate, be prepared to do it at the first onset of dangerous symptoms. In such circumstances procrastination may be regarded not only as a thief, but a murderer."

REMARKS ON THE OPERATION OF EXCISION OF THE BREAST AND ITS

AFTER-TREATMENT.

GOULD (Lancet, London, 1892, vol. i., No. 8) speaks of certain special points concerning this operation. In the matter of the direction of the incision, the author states that two considerations only should guide the surgeon. The first is imperative and has to do with the complete removal of the nipple and skin over the tumor, when that is malignant. The second is to have the cicatrix parallel to the fibres of the pectoralis major. In most cases both of these objects are best attained by the same incision-one enclosing an ellipse of skin parallel with the anterior fold of the axilla when the arm is at a right angle with the trunk. It is stated that it is sometimes convenient to prolong the incision into the axilla, but never necessary, as the axilla can be readily reached from any incision for amputation of the breast. The writer has thoroughly cleaned out the axilla in two cases of scirrhus of the breast, through an elliptical incision over the gland, the long axis of which was vertical.

When the mamma is not the seat of malignant growth, it is recommended not to invade the axilla, and even in cases of sarcoma the axillary glands are not to be removed unless affected. In cases of carcinoma, however, the glands should be removed from the axilla, together with the mass of fat in which they are situated. The intercosto-humeral nerve should be preserved.

Bleeding vessels are caught with pressure-forceps as fast as they are cut. At the conclusion of the operation the forceps are carefully removed. Occasionally one or more arteries will require twisting. A ligature is never necessary. Sponges are used only to dry the wound and are never to be rubbed over its surfaces. The less they are used the better.

The wound is to be thoroughly flushed with bichloride solution 1:2000. A continuous suture of fine chromicized catgut is recommended, each loop being caught up the buttonhole stitch. A drainage-tube is not to be employed.

The dressing should be aseptic and it should secure accurate apposition of the wound-surfaces. The author uses four layers of boric lint to lay over the wound, the margins extending an inch beyond the wound in all directions. This is held in place by strips of plaster two inches wide. Over this, gauze or wool is applied, and held in place by a roller bandage carried around the trunk in an ascending figure-of-8. The arm is held to the side by means of an ordinary chamber-towel. The towel is folded lengthwise, and between the two folds the forearm and arm are placed, the hand being just within one end. The towel is then fixed in place by pins.

During the first twenty-four hours a firm pillow placed under the arm of the affected side may relieve the usually distressing backache. After the first day the patient may be raised to a sitting position by pillows or a bed-rest. The dressing may be removed on the seventh day, when the stitches may be carefully taken out. The wound is re-dressed by two layers of sublimate gauze, fixed with collodion, and over this a light boric lint dressing held with the roller bandage.

[It is interesting to note the various methods adopted by different surgeons in the performance of this most common operation and in the after-treatment of the patient. It may be freely admitted, however closely one is wedded to his own particular plan, that it is possible to obtain equally good results by many others apparently very unlike but based on sound operative principles. But the teaching that in these cases a ligature is never necessary," and that "one or more arteries will require twisting," as though the bleeding-points were likely to be very few, is unsafe and liable to lead to frequent and large accumulations of blood beneath the flaps. It is sounder surgery to tie all active bleeding-points and not to depend to any extent upon pressure for hæmostasis. "Flushing a wound thoroughly" with 1: 2000 bichloride almost always necessitates the employment of a drainage-tube to carry off the excess of serous exudate which inevitably follows. To sew up such a wound with a continuous suture is further to invite the retention of wound secretions, tension of flaps, etc., and to favor in the highest degree the occurrence of putrefactive changes in the wound, if by ill-luck the least infection has occurred. The continuous suture is open to the further objection that in thin and poorly nourished flaps it interferes too much with the circulation in the wound edges and thus prevents rapid union, or even occasionally produces a linear necrosis. Nothing but the evidence of large numbers of cases, carefully reported in detail, could overcome these objections in my mind to the above method.-J. W. W.]

ATTEMPTED LITHOTRITY IN A BOY; SUPRA-PUBIC LITHOTOMY.

CLEGG reports (Lancet, London, 1892, vol. i., No. 13) the following case: A boy, aged ten years, had had retention of urine demanding catheterization when seven weeks old, and suffered more or less from urinary trouble since. He walked cautiously and bent forward. He had retracted testicles, a long foreskin, and a prolapsed rectum. The urine was fetid.

A stone had been diagnosticated and an attempt was made to crush it with a No. 8 lithotrite. After considerable difficulty the stone was caught, and on screwing down the instrument the soft outer coating readily gave way, but the stone resisted efforts at crushing, and when considerable force was applied it invariably slipped from the grasp of the instrument. It was, therefore, considered advisable to perform supra-pubic lithotomy. The patient was arranged on the back of an inverted chair placed upon the operating-table. A sponge was used to distend the rectum in the absence of a rectal bag. The operation was performed without difficulty and the stone extracted. It measured two inches in length by one and one-eighth inches in breadth, and weighed 370 grains, without the débris. The bladder-wound was anchored to the abdominal wound. On the eighth day urine was passed by the urethra, and four weeks later the abdominal wound had healed. The recovery was complete; the boy is now attending school, and he has changed wonderfully in appearance.

The author speaks enthusiastically in favor of lithotrity in the majority of cases, and believes it to be the safest operation for stone if the kidneys are affected. The completely fenestrated lithotrite is recommended, and Nos. 6, 8, 10, A, B, and C will meet all requirements. The Weiss-Thompson is preferred to the Bigelow handle. The most convenient aspirator is the latest Bigelow pattern.

INTESTINAL ANASTOMOSIS AND SUTURING.

ABBE, after reporting several cases of lateral intestinal anastomosis (Medical Record, N. Y., vol. xli., No. 14), considers the different methods for accomplishing this purpose. He objects to plates of bone, potato, or catgut, for the reason that the foreign bodies may cause obstruction, that leakage may occur, and in the case of Senn's plates, on account of the necessarily limited size, the opening in the bowel becomes, after contraction, inadequate for the performance of its function. The few extra minutes required to do the method of simple suturing does not add any complication to the case, while the security against leakage and blocking is of great value.

The author has had the opportunity of making an autopsy on three cases in which he had performed lateral anastomosis. In the first case Senn's plates had been used. The patient died six months after operation. The aperture made in the bowel at the time of operation was one and one-half inches in length. It had contracted to three-fourths of an inch, and was inefficient, except when laxatives were employed constantly. In the second case, the patient had died six months after anastomosis with catgut rings. The opening had contracted from one inch and a half to half an inch. In the third case, eight months after lateral anastomosis of the sigmoid by suturing, the aperture had contracted from three inches to one and one-half inches. This was perfectly competent to perform its functional work.

It is believed that the future utility of lateral anastomosis depends upon openings four inches in length in the sides of the adjacent bowel. This is almost impossible with bone plates, and only to be carried out with very long catgut rings or vegetable plates, and with less security and as much consumption of time as by suturing. The contrast is enormous between drop

ping back into the abdominal cavity an accurately sutured, absolutely tight and flexible, anastomosed intestine to any position in the cavity which its surroundings demand, and the returning of a huge bunch of bowel, inside of which there is a pair of five-inch plates of bone or raw potato, to remain as irritating foreign bodies stimulating peristalsis and tugging at the wound until they are sufficiently softened to be carried away.

It is recommended, in cases of great fecal accumulations, to first establish an artificial anus and allow some days for recuperation, when the anastomosis may be performed.

The technique of simple suturing is thus described: "Bring the two surfaces that it is proposed to unite well up in the wound and surround them by small compresses of gauze, towels, or flat sponges wrung out of hot water. Have at hand half a dozen fine cambric needles threaded with the ordinary finest black embroidery silk that has been well boiled and kept in alcohol. Cut in lengths of not more than twenty-four inches and tie with a single knot at the eye of the needle, with one end cut to within two inches. Apply two parallel rows of continuous Lembert sutures a quarter of an inch apart and an inch longer than the proposed cut. Leave each thread with its needle attached at the end of its row. Now open the bowel by scissors, cutting a quarter of an inch from the sutures, both rows of which are to remain on one side of the cut. Make the bowel opening four inches long. Apply clamps temporarily to several bleeding-points, pinching the entire cut edge without. hesitation. Apply no ligatures. Treat the apposing bowel in the same manner. The clamps remaining in situ, the parts are quickly rinsed with water. Another silk suture is now started at one corner of the openings and unites by a quick overhand the two cut edges lying next the first rows of sutures. The needle pierces both mucous and serous coats, and thus secures the bleeding vessels, from which the clamps are removed as the needles reach them. This suturing is then continued round each free edge in turn, and all bleeding-points thus secured more quickly than by ligature. The serous surfaces around these buttonholes are then rapidly secured by a continuation of the sutures first applied, the same threads being used, the one nearest the cut edge first. The united parts are again rinsed with water and dropped into place.

In conclusion, Abbe reiterates his conviction: 1. That the attempt to simplify the technique of lateral anastomosis by bone plates and other devices has not improved it. 2. That lateral anastomosis properly done is eminently the safest and best method of restoring the canal in most cases. 3. That simple and thorough suturing with a fine silk continuous suture, applied after the manner detailed, is most satisfactory. 4. That in order to allow for the inevitable tendency to stenosis, an aperture four inches long should be made. 5. That scarifying apposing surfaces in entirely unnecessary to quick and solid repair.

[In a recent case of strangulated inguinal hernia operated upon by this method, I found that one row of the continuous Lembert sutures was sufficient to produce satisfactory apposition and complete isolation of the intestinal aperture. The bowel had been tightly constricted for forty-eight hours, and ten or eleven inches were gangrenous. The patient was already septic and much shocked. It was absolutely necessary to minimize the time of the

operation, and, indeed, the abdominal sutures were inserted with the patient almost inverted on account of increasing shock. Under such circumstances it is imperative to save every moment, and more time is usually spent upon the application of these sutures than upon all the rest of the operative procedure. The double row is most desirable when the operator is not hurried, but it is worth noting that a single row can be made exceptionally to do the work.-J. W. W.]

TREPHINING FOR CEREBRAL NEOPLASM.

NIXON describes (Med. Press and Circular, vol. civ., No. 9) the case of a man, aged twenty-eight years, who suffered from attacks of giddiness, forgetfulness, and defective vision. There was a history of syphilis. Later, intense pain in the head developed, which extended round the forehead and down the neck. Paralysis of the left leg and arm followed, and double optic neuritis was discovered. The patient was dull. Control of the sphincters was lost.

The operation of trephining was performed at the right parietal eminence, as this was the former site of a suppurating sebaceous cyst, and it was thought that perhaps an abscess might have developed beneath the skull. The bone was extremely dense and half an inch thick. The meninges were matted together and thickened. A hard, cartilaginous substance was seen dipping deeply into the brain, and running forward toward the fissure of Rolando. A portion also ran inward toward the falx cerebri. The neoplasm was removed and the wound treated by the usual methods. When the patient recovered from the anaesthetic he was quite conscious, was free from all pain, and was able to move both his arms and legs. Control of the bladder and rectum also returned. The patient did well for some five weeks, when a hemorrhage occurred from the wound, which was the site of a cerebral hernia. Styptics were applied and the wound re-dressed. The patient became comatose, and died some hours later.

This is believed to be the first case in Ireland in which a solid growth has been successfully removed from the cranial cavity.

THE TREATMENT OF TUBERCULOUS ABSCESSES CIRCUMSCRIBED IN THE RETRO-VISCERAL REGION.

KRAMER (Centralblatt f. Chirurgie, 1892, No. 12), emphasizes the fact that in spite of the great attention paid to tubercular abscesses in most regions of the body, in recent years, the treatment of similar cellections in the retrovisceral space has not kept pace. Antiseptic methods should be employed in these cases as well as elsewhere. Retro-pharyngeal abscesses have been treated by evacuating simply. It will not be feasible to attack the diseased bone in most cases, but thorough antiseptic treatment should be carried out. These abscesses can be readily reached from an incision in the neck. This has already been tried, but has not been followed by surgeons in cold, as well as acute and phlegmonous, abscesses of the retro-pharyngeal space. Chiene, in 1877, did this operation by making an incision from the mastoid process, along the posterior border of the sterno-mastoid muscle, and keeping along the anterior surface of the spinal column. Burckhardt made his