the surgeon, assured that the death will not be laid to his door, can accept the responsibility of treatment with greater confidence, and the success of his efforts will not be jeopardized by nervous apprehensions of failure.-Med. Record.

CHOLECYSTOTOMY. W. G. Macdonald, M. D., in Albany Med. Annals.—In 1733, Petit communicated to the French Academy a remarkable paper on "Tumors Formed by Bile Retained in the Gallbladder," in which he advocated abdominal incision into the adherent gall-bladder, the attachment of the gall-bladder to the abdominal wall, and lithotomy for biliary calculus. He also gave the history of a case in which this procedure had been adopted successfully. Petit's contribution, not unlike many other ones advocating innovations in the methods of treatment, was either adversely criticised or received but little attention.

In 1859, Thudicum recommended abdominal section, suturing the unopened gall bladder to the abdominal wound and opening it several days later after adhesions had formed. Between 1733 and 1859, the expectant plan of treatment had been followed, or rarely the use of caustics to secure adhesion of the parietal peritoneum to the distended gall-bladder. Bobbs first performed cholecystotomy, in Indiana, in 1868. The cystic duct was found closed and the gall-bladder distended. A small incision was made into the gall bladder, and fifty calculi removed. The wound of the gall-bladder was united with a single stitch, the abdomen closed, and the patient recovered. J. Marion Sims, in 1878, first intentionally operated for gall-stones, and, although the case terminated fatally, the method of operation which he subsequently described has remained unmodified. Lawson Tait, who has operated oftenest, and with greatest success, credits Sims with having perfected the operation,

Greig Smith gives four indications for the operation:

I.

2.

Wounds and perforations of the gall-bladder.

Obstruction of ductus communis choledochus, or common duct. 3. Dropsy or empyema of the gall-bladder.

Wounds of the gall-bladder, whether due to traumatic causes or to the process of ulceration, have been uniformly fatal. The presence of bile in the peritoneal cavity, whether it contains, as Mr. Tait thinks, a special ferment or not, has uniformly lighted a virulent peritonitis.

Obstruction of the common duct may occur from cancer of the liver, stomach or pancreas, from intestinal parasites, from ulceration in

catarrhal jaundice and subsequent stricture, and from bands of lymph. However, biliary calculus is the most common cause. It is in these cases that obstructive jaundice, with its attendant symptoms, occurs.

Untreated or medicated, the histories of these cases have been, unfortunately, a source of great anxiety to the physician. The pain, the progressive emaciation, the development of the hemorrhagic diathesis and other circulatory disorders, the intolerable itching which is almost pathognomonic of obstructive jaundice, the abdominal distension, the nausea and vomiting, are often, only relieved by the onset of coma, soon to be followed by death. Nor are these the only consequences. Rupture of the gall bladder from over-distension, or gangrene of the common duct, lead to a fatal peritonitis.

Dropsy and empyema of the gall bladder are often found in conjunction with obstructive jaundice. It is in cases where the cystic duct is occluded that we have distension of the gall- bladder without jaundice.

The use of the aspirator in dropsy or empyema of the gall-bladder is no longer regarded as justifiable. Simple aspiration has been followed by death from hemorrhage, peritonitis and enteritis. Greig Smith says: "I look upon the proceeding with no favor whatever. It can neither be curative nor of great diagnostic value."

In cases of biliary colic where jaundice and clay-colored stools are not present, we conclude if the paroxysm of pain continues after sixty or seventy-two hours, that the calculus lies in the gall-bladder or cystic duct. Biliary colic of short duration is often unaccompanied by jaundice.

Finally, the fourth indication, cholelithiasis, seems to me the one which will oftenest commend itself to us.

Biliary calculi may be large and few in number, rarely single, or small and very numerous. A single large calculus may give rise to continued attacks of colic, dropsy, empyema, gangrene or perforation of the gall-bladder, and to obstruction of the biliary duct and jaundice. It may cause ulceration of the walls of the gall-bladder and discharge itself into the stomach, intestines, bladder, general peritoneal cavity, or externally. It may cause, secondarily, peritonitis, cholemia, parenchymatous changes in the liver, and obstruction of the bowels. When the calculi are small, repeated attacks of biliary colic unfit the patient for work, and cause quite as much distress physically, if not mentally, as salpingitis, for which the abdomen is opened every day; nor are they free from all the dangers occurring with larger calculi. Dr. Loomis says; "In fact, we can never feel easy about a case of biliary colic." I am not unmindful

that there are cases of biliary calculi that never give rise to any symptoms, that there are cases that have one or two attacks of biliary colic and then fully recover without treatment, and that there are a considerable number that are either improved or cured by medical agents. But, so far as my reading goes, authors dwell at length upon the treatment of the paroxysms and the preventive treatment, but do not advocate with enthusiasm or uniformity any particular method of curative treatment.

In the condition of colelithiasis the following conditions are indications for operative treatment:

1. Jaundice proceeding to cholemia.

3.

2. Repeated and severe or prolonged attacks of biliary colic. Continued pain in the right hypochondrium or epigastrium. 4. Dropsy or empyema of the gall-bladder from presence of gall-stones.

Is the operation of cholecystotomy dangerous to life?

The question can best be answered on examination of published cases. Musser and Keene (American Journal of the Medical Sciences, Oct., 1884) gives a table of all published cases up to that time—thirtyfive in all. I have been able to find the history of ninety-five other cases, with operations, making in all 130 operations, with 108 recoveries and twenty-two deaths. Mr. Tait has reported in all fifty cases, with two deaths. The remaining seventy cases were operated upon by a large number of surgeons in this country and abroad. Of the cases operated upon prior to 1884, as tabulated by Musser and Keene, twenty-five recovered and ten died. Of the reported cases collected from the journals, and occurring between 1884 and 1889, eighty-three recovered and twelve died.

A study of the causes of death in the combined table shows that eleven cases, one-half of the mortality, died from hemorrhage, exhaustion and cholemia.

Patients that have suffered for a considerable time from obstructive jaundice are unfavorable ones for operation. Changes in the blood predisposing to secondary hemorrhages, and parenchymatous changes in the liver have already taken place, which, together with the emaciation and exhaustion, have been unusually fatal. Two deaths were due to extravasation of bile in cases where the wound in the gall-bladder had been closed by suture and returned to the abdomen, a procedure no longer advocated or adopted. Five cases died from peritonitis. In those cases difficulty was experienced in separating adhesions, or a contracted or ob

literated gall-bladder complicated the operation. Keene, Parkes, and others have been compelled to abandon the operation. Three died from the more serious operation of cholecystectomy, or removal of the gallbladder. One (Gross' case) was complicated by an operation for the removal of the kidney.

The curious relation of biliary calculi to cancer of the liver is somewhat remarkable. Several cases have died secondarily from cancer of

the liver.

Aside from the results in the cases where the condition of jaundice had existed for months, the results are very gratifying. It seems to me that operation must become more general in its application to the treatment of the diseased conditions found in the gall-bladder and ducts.

EXCISION OF KNEE-JOINT.-Prof. John A. Wyeth, of New York, gives the following directions for the performance of this operation (Med. Record): Under the strictest asepsis the leg is cleaned, the foot elevated to empty the extremity of blood, and a rubber tube tourniquet applied above the middle of the thigh.

With the leg straightened out, an incision is made across the center of the patella, and down on each side, until the level of the posterior surface of the tibia is reached. These points must be low in order to secure free drainage. The skin flaps or cuffs are now dissected and rolled up until the upper one is turned back from two to three inches, the lower about one and a half inch. As the flaps are held well away by assistants, the operator cuts down to the femur through the tissues, parallel with the attached edge of the reflected flap, lifting everything from the anterior aspect of the femur and its condyles, together with the patella, the attached fringes, ligamentum patellæ, and coronary ligaments, thus clearing in one mass all the tissues which envelop the anterior threefourths of the joint.

By sharply bending the knee the crucial ligaments are exposed and divided, the lateral ligaments cut away, and the disarticulation effected. In stripping the attachments of the ligamentum posticum Winslowii from the tibia and femur, the operator should closely hug the bone, and thus avoid wounding the vessels. This dissection should extend about threefourths of an inch below the level of the tibia, and one and a half inch above the lowest surface of the condyles. Determining now the amount of bone necessary to be removed, a cloth retractor is applied so as to protect the soft parts from bone detritus or injury, and a slice thick

enough to freshen the head of the tibia is sawed away, as nearly as possible parallel with the normal plane of the articular surfaces. Should the section expose a focus of disease which dips down into the bone, this should be cleared out with a scoop or Volkmann spoon, and finally mopped with a strong bichloride solution (1 to 500).

The section through the end of the femur should now be made. It follows that if the limb is to be straight in the position of anchylosis the sawed surfaces of the two bones must be parallel. I have found it of great value to employ this method. By pulling on the foot the limb is fully straightened, and the articular surface of the femur separated from the sawed surface of the tibia. If the operator will now start the saw into the femur, sighting by the flat face of the tibia, the instrument will cut directly parallel with this. If by error the section of the tibia has been slightly oblique, that of the femur will have a like obliquity, and, there fore, the bones will fit snugly with the extremity straight.

The next step is to dissect away with forceps and curved, blunt scissors all the diseased capsule. This should be done thoroughly, and even the bursæ that communicate with the joint should be cleaned out. If care is not taken, a portion of the sac which extends up beneath the quadriceps tendon will not be removed. All bleeding points should be tied with catgut and all hemorrhage stopped. The bones are now brought in exact opposition, and while so held the steel drills are introduced. I usually carry two of these in from below upward, passing them through the skin about two inches below the sawed surface of the tibia, and directing them obliquely through the tibia into the femur. When the end of the drill has reached the compact substance of the femur, it is stopped, the handle unshipped, and the drill left in position. Three are used, one on either side from below, and one directly down the median line from above, entering the femur and passing into the tibia.

As the leg is now held steady, the edges of the wound in the skin are sewed together with catgut, and two short bone-drains inserted at the inferior angle. I no longer use rubber drains, having had considerable trouble with the sinuses that persist after their removal. If the absorbable bone-drain is not at hand, twists of catgut will suffice. Aseptic dressings and layers of veneering as a splint are applied under firm com. pression of a roller. Over all one layer of starched crinoline bandage is placed. This dressing is allowed to remain on for from two to three weeks, and when changed the drills are pulled out.