aspiration. So much difficulty in this part of the treatment was not anticipated. In a postscript to the original paper it was stated that on returning to work (without leave) and to his former habits as to diet, the patient became ill; after a month was readmitted with a small pleural, but no pericardial, effusion, and died suddenly on the second day. At the autopsy the heart was found universally adherent to the pericardium; the pericardium was adherent slightly to the left lung, firmly to the right lung. The base of the right lung was firmly adherent to the diaphragm, which in turn was firmly adherent to the liver. It was merely a nutmeg liver, there was no cirrhosis. The arteries showed scarcely any atheroma. The kidneys were rather hard, but apparently sound, resembling organs from a case of initial disease. The valves of the heart were normal.-Medical Press, No. 2741. SURGERY. UNDER THE CHARGE OF J. WILLIAM WHITE, M.D., PROFESSOR OF CLINICAL SURGERY IN THE UNIVERSITY OF PENNSYLVANIA; SURGEON TO THE UNIVERSITY AND GERMAN HOSPITALS; EDWARD MARTIN, M.D., CLINICAL PROFESSOR OF GENITO-URINARY SURGERY IN THE UNIVERSITY OF PENNSYLVANIA; SURGEON TO THE HOWARD HOSPITAL AND ASSISTANT SURGEON TO THE UNIVERSITY HOSPITAL. RESECTION OF THE GUT. Four cases of resection of the gut are contributed by BARRACZ (Archiv für klin. Chir., Band xlii., Heft. 3). Three of these cases were on account of gangrene following strangulated hernia; they all recovered. The fourth operation was necessitated by a sarcoma in the region of the ileo-cæcal valve, complicated by invagination. The patient died twelve hours later. To these cases is appended a statistical study of primary resection as required by gangrene of the gut. The general mortality of all these cases varies between forty and fifty-six per cent., yet, as the author points out, these tables are of little value in determining the real death-rate, as the great majority of cases are not reported. The statistics of resection of the large intestine for the cure of new growths give about the same mortality. The author, from his personal experience and from a statistical study of the subject, draws the following conclusions: 1. In cases of gangrene of the gut, primary resection is indicated only when strangulation is not of long standing, when collapse is not present, when there are no signs of peritonitis, when the hernial sac is not gangrenous, or is not violently inflamed. 2. Where such counter-indications are present the operation should be limited to the forming of an artificial anus. 3. In case of artificial anus, resection of the gut is indicated when the opening cannot be closed by repeated use of the Dupuytren forceps, or by plastic operations. Operation is further required in cases of prolapse or of stricture of the gut. The patient should be carefully prepared for operation by a nourishing diet. Resection of the gut and enterorrhaphy is contra-indicated in cases of preternatural anus when there are strong adhesions, such as result from localized peritonitis. The breaking up of these adhesions may either cause peritonitis from tearing of the gut and an extravasation into the peritoneal cavity, or may occasion shock. In such cases a lateral anastomosis between the loops of gut above and below the position of the natural opening is indicated. Senn's method is to be preferred in this case. In cases of tumor of the large intestine, resection of the gut with either enterorrhaphy or anastomosis is only exceptionally indicated, namely, in small and movable tumors, and when the strength of the patient is well preserved. In well-developed tumors, and where cachexia is marked, resection of the gut and the formation of a preternatural anus or enterostomy is indicated. In case of new growth of the cæcum or the ileo-cæcal valve, resection of the diseased area, with the formation of an artificial anus, or of lateral anastomosis, are indicated. The lumbar incision, namely, that adopted in retro-peritoneal nephrectomy, is well adapted to cæcal tumors, especially in cases where the differential diagnosis between involvement of the cæcum and kidneys is not exactly made out. The technique of enterorrhaphy as practised on the Continent is a surgical procedure requiring far too much time. The quicker method, recommended by Senn —that is, lateral apposition by means of decalcified bone plates-on account of the ease and rapidity with which the operation is completed, would seem to be preferable to enterorrhaphy. ANEURISM OF THE INNOMINATE AND PRIMITIVE CAROTID ARTERIES. LE DENTU (La Méd. Md., No. 42) reports a case of aneurism of the innominate artery involving the lower portion of the primitive carotid, which was treated by a simultaneous ligature of the carotid artery and the right subclavian. The patient died forty-four days after operation. The immediate results of surgical interference were fairly satisfactory. No complication resulted, and the pulsation of the aneurismal sac seemed to be diminished, but the heart again became very much more rapid. Two weeks after the operation the rapidity of the pulse again became reduced to normal. The patient suffered for a while from delirium and great restlessness. These symptoms yielded to sulphonal. The improvement was only temporary, the aneurism then steadily became larger, and the patient finally died from gradual asphyxia. The author enters into a statistical study of the treatment of innominate aneurism. Walther's cases are cited. This author found that treatment of innominate aneurism by ligature of the subclavian alone, gave in three cases satisfactory results for a time, but no definite cures. Of twenty-five cases of ligature of the carotid alone, those in whom the dilatation also affected the aorta died shortly after operation. Of thirteen cases where the aneurism was limited to the innominate, nine died; in only two was slight amelioration observed. Those cases in which both branches of the innominate were tied, gave four deaths and two cures, the latter being reported twenty months and nine years respectively after the operation. Of the twenty-five cases, therefore, twenty-one died. Of eight cases in which the carotid was first tied and a ligature was subsequently placed around the subclavian, five died and three were cured. Of thirty-five cases in which there was simultaneous ligature of the primitive carotid and subclavian, there were fourteen cases in which the results were satisfactory; twelve of these cases have been published since 1882, of these ten were cured and only two died. Winslow has collected fifty-nine cases of ligature of the common carotid and subclavian with forty-three cures, in so far as the operation was concerned. Sixteen of these cases were completely cured. Of the remaining cases twenty were decidedly benefited. Le Dentu makes an interesting comparison between the results of ligature in the pre-antiseptic times and those observed when the operations were conducted according to modern methods. Pre-antiseptic cases gave a mortality of 66 per cent., those treated antiseptically gave a mortality of 22.64 per cent. The thirteen cases of aneurism of the aorta treated by ligature of the carotid and subclavian are added to the statistics collected by various authors. Four of these died between the fifth and twenty-first day after operation. Four others lived for a period varying between one to four years; five have been recorded as completely cured. As a result of statistical study, Le Dentu concludes that, as a general rule of procedure, aneurism of the innominate artery should be treated by simultaneous ligature of its two main branches. TREPHINING FOR FRACTURE of the Vertebral Column. To the rapidly growing literature concerning surgical intervention for the relief of paraplegia dependent upon traumatism of the vertebral column, WEISS (La Mercredi Médicale, No. 38, 1891) contributes a successful case of trephining. The patient fell from a height of about thirteen feet, alighting upon his buttocks. On examination shortly after the injury, there was a marked backward projection of the spinous process of the eleventh dorsal vertebra. There was complete paralysis, motor paralysis of the left leg, and partial paralysis of the right leg. There was no alteration in either sensibility or reflexes. Both the bladder and the rectum were paralyzed. The first treatment consisted in the application of an immobilizing apparatus. Paralysis of the bladder persisting, catheterism was resorted to, and this resulted in cystitis. A huge bedsore formed over the scrotum. About two months after the injury the patient seemed to be steadily sinking, and operation was determined upon. The spinal cord was exposed and was found somewhat thinner than normal at a point corresponding to the backward projection of the vertebra. No sign of either curvature or displacement was detected on operation. The dura mater was opened, the wound was drained and united, an antiseptic dressing was applied, and a plaster-jacket was put on. The improvement in the patient's condition was marked and progressive. Nineteen days after operation, movement returned to the limbs, the patient had regained partial control over his bladder, and the bedsore was practically healed. Three and a half months after operation the patient could walk readily, and ultimately completely regained his health. It is evident in this case that there was not complete disruption of the spinal cord, since sensibility was retained. CHOLECYSTECTOMY. An interesting résumé of the indications for the performance of cholecystectomy, and the technique of the operation, is given by GUILLEMAIN (Gaz. Heb. de Méd. et de Chir., No. 39, 1891). The indications for this operation are usually considered to be covered by the following conditions: traumatic or spontaneous perforation of the gall-bladder, tumors, rebellious hepatic colic, or persistent biliary fistula, the operation being contra-indicated only by very extensive adhesions or by occlusion of the common duct. Removal of the gall-bladder under all these circumstances is perhaps too radical, since cholecystotomy, with or without the formation of a fistula, or cholecystenterostomy, may sometimes take the place of the more radical operation. In performing the operation median incision should be made, since this allows of more thorough exploration, and, moreover, renders the cystic duct more accessible. The incision should be made of sufficient length to give the operator sufficient room to manipulate below the umbilicus, if necessary. As soon as the abdominal cavity is opened, the omentum and intestines should be carefully protected by sterilized compresses or sponges, whilst the surgeon exposes the anterior portion of the gall-bladder. Frequently it is necessary to puncture this and discharge its contents, to lessen the danger of infecting the general peritoneal cavity. When this has been done, the gallbladder is incised and the finger is introduced for the purpose of exploring its cavity and removing calculi. This latter object is thoroughly accomplished by means of forceps and curette. If the gall-bladder is fully freed, the biliary ducts should be carefully explored by palpation and by means of catheters. A calculus lodged in the ducts can usually be readily felt by passing the finger along the course of the latter. If the surgeon fails to pass the catheter this does not necessarily denote that the duct is occluded, since the passage may be either very small or temporarily closed from external pressure. The gall-bladder usually contracts firm adhesions with the neighboring organs, and separation of these organs constitutes one of the most difficult steps of the operation. This should be accomplished by blunt dissection as far as possible, all bleeding portions being secured immediately by means of the hæmostatic forceps. When the inflammatory adhesions have been entirely separated the gall-bladder must be loosened from its normal attachments to the lower surface of the liver. This also should be accomplished by blunt dissection. Often the gall-bladder is surrounded, particularly where it is in contact with the liver, by a fatty degeneration forming an investment from which it can be enucleated, leaving this fibro-fatty capsule as a barrier between the seat of operation and the general peritoneal cavity and allowing free drainage in the latter. When the gall-bladder is fully freed, isolation and ligature of the cystic canal constitutes the next step in the operation. This is exceedingly difficult. The ligatures should be applied as deep as possible without including the right branch of the hepatic artery or the common duct. The ligature should be of silk, and the portion left after division should be very carefully disinfected either by solution of bichloride, 1:1000, or by means of the thermo-cautery. So far as it is possible, there should be an effort made to form a cavity separated from the general intra-peritoneal space in which the drainage-tube is placed. This may be accomplished by suturing to the parietal perineum the right border of the great omentum and utilizing in a similar way, when these structures exist, the ligamentous connection between the liver and colon, so as to form between these a furrow in the deep part of which lies the divided duct, and in which the bile will be poured out in case the ligature slips. The seventh day the drainage-tube is removed. The complications of this operation are hemorrhage, peritonitis, and septicemia, usually due to some fault on the part of the operator, and effusion of bile into the peritoneal cavity. The last complication is most to be feared, and takes place when there is occlusion of the common duct. Of 78 cases collected by Calot, 64 were cured, and 14 died; this gives a mortality of about 18 per cent. The majority of cases, however, perished from causes not directly due to the operation, hence the true mortality, as far as the surgical procedure is concerned, is 8.9 per cent. According to Langenbuch, after cholecystectomy the pains of cholelithiasis completely disappear, digestion becomes normal, and there is a great improvement in general health. The conditions particularly favoring a successful result of this operation would seem to be a permeable condition of the common duct, and the permanent obliteration of the cystic duct when found in combination with adhesions which are neither very extensive nor very firm. OTOLOGY UNDER THE CHARGE OF CHARLES H. BURNETT, M.D., CLINICAL PROFESSOR OF OTOLOGY IN THE WOMAN'S MEDICAL COLLEGE OF PENNSYLVANIA, INDICATIONS FOR EXCISION OF THE HAMMER AND ANVIL, DR. STACKE, of Erfurt, after presenting an excellent account of the origin of this important operation, and the results in the practice of numerous aurists, gives his own experience and an account of a modification of the operation (Archiv für Ohrenheilk., Bd. xxxi., p. 201). Finally, the indications for the operation are presented. The modifieation of Stacke consists first in loosening the auricle, as practised by Schwarze for the removal of impacted foreign bodies in the ear. A curved incision is made close to the insertion of the auricle, passing down to |