as we appreciate more that the gall-bladder, like the appendix, when full of strictures, is best taken care of in a specimen-bottle filled with a good preservative.

The chronic cases, when the gall-bladder is a mass of scar tissue, contracted, thickened and obstructed, a cholecystectomy should be performed. A third method, and one that usually brings results that are all that could be desired, is by making an anastomosis between the gall-bladder and some part of the intestinal canal, the jejunum being the preferable site.

A class of patients will be met with occasionally who are in a desperate physical condition, and in no shape to stand a prolonged surgical procedure, in whom, at time of operating, an enlarged gall-bladder is found surrounded by firm vascular adhesions, and in whom no stone can be found by palpation in the common duct, yet that canal is obstructed; in such cases a chloecystectomy would be the proper procedure.

In making the anastomosis I believe that the Murphy button gives the largest opening, the most permanent and satisfactory results. This operation, in properly selected cases, is to be preferred to all other methods of relieving the individual of his burden of taking care of the bile in his blood. Many cases of narrowed pylorus and dilation in the stomach have their origin in adhesions surrounding biliary ducts, and are relieved by proper separation of the adhesions and removal of the cause of the adhesions.

There is a class of cases presenting an obscure train of symptoms pointing to the vicinity of gall-bladder and biliary ducts as their source as a vague sense of uneasiness, occasionally painful spells lasting a few minutes, with attacks of indigestion and painful flatulency. At the operation no stones are found, no stricture of ducts are discovered, no visible changes in gall-bladder are discernible-in fact, nothing is detected except a few adhesions between cystic duct and common duct or duodenum. A separation of these adhesions, with a liberation of the bound-down ducts and viscus from the constantly nagging, distended stomach and intestines, will, as a rule, bring relief to the patient.

The all-important question of early diagnosis is ever present in all pathologic processes. A diagnosis in the early history of most surgical cases would rob those cases of their later destructive process to the organ affected and ward off damage to remote organs. simple process by time and complications becomes one of danger, and much more diffi

A

cult to deal with surgically. Add to a delayed diagnosis professional tardiness in recommending the proper method of relief and the opposition of the patient to accept professional relief, and we have all that is necessary for the development of serious complications. It makes the surgery difficult, attended by a too high mortality, and a failure often to relieve syptoms and a protracted convalescence.

I report this unusual case of non-lithogenous obstruction of common duct to illustrate the remote and irreparable damage to other organs the spleen and the liver.

CASE II.

Mr. R., aged twenty-one. At the age of three years this young man's parents noticed that he was jaundiced, and even before that time he had attacks of pain, very severe in character and of long duration. These attacks of "colic, so called, continued to recur at irregular intervals, to be followed by an increase in the jaundice. The skin has never cleared entirely since the beginning of his attacks. The stools have at times been acholic, but, as a rule, there has been evidence of some bile in the feces.

When I first saw him I found him jaundiced, Pulse poorly nourished, careworn and exhausted. 58, temperature 97.5°, poor appetite, inability to digest much fatty food, stools only faintly bile-stained; urine, specific gravity 1035, loaded with bile.

Examination.-Abdomen enlarged on left side, dullness over area from rib border to crest of ilium. No tenderness on firm pressure at any point. Nothing in liver or gall-bladder region could be detected on palpation or percussion. No fluid in peritoneal cavity.

Diagnosis.-Common-duct obstruction, probably congenital or cicatrical; enlarged spleen, as result of circulatory interference in liver.

Operation.-Usual parietal incision for a commonduct operation. Tissues, when cut, locked like a carrot. Bled very freely from smallest of vessels; spleen enlarged, not nodulated; gall-bladder thickened and slightly enlarged. No stones in gall-bladder or in any of the hepatic or common ducts. Just where the common duct passed under the first portion of the duodenum the duct was hard as a tendon, and appeared to be in very much the same pathologic condition that is found in appendicitis obliterans (cholangitis obliterans). The gall-bladder was opened and explored carefully with probe to establish the patency of cystic duct. An anastomosis was made by the aid of a Murphy button with upper portion of the jejunum. His recovery was the usual one of

a successful abdominal section. The stools soon became bile-stained, his skin began clearing at the end of three days, and at the end of five weeks was quite clear for a skin that had been bile-stained for eighteen years. His appetite for fats developed soon, and his weight rapidly increased. His attacks of pain disappeared. I heard from him this week, one year after the operation, and he weighs 160 pounds and is feeling fine. The button passed on the seventeenth day after the operation.

This case is one of much interest because of the character of the pathology, duration of the same, and the rapid restoration of the patient's health. The changes in the liver

and spleen produced by long-continued duct obstruction, I am afraid, are of such a character that a permanent and satisfactory cure will not be obtained in this case.

Traumatism in the vicinity of the ducts may lead to a stricture of the duct, as the following case illustrates:

CASE III.

Mr. aged fifty-five. Some three years ago received a kick over the liver, from a horse; this led to a severe attack of localized peritonitis. His symptomatic recover was tardy. One year ago he began having pain in the region of the gall-ducts, and soon a jaundice developed, that has persisted up to the time I first saw him. An operation revealed extensive adhesions and the canal of the common duct obliterated for an inch and a half. An anastomosis was made between the gall-bladder and the jejunum; his pain, jaundice and other symptoms disappeared from that time to the present, two years later.

CASE IV.

Mrs. T., aged forty-five. This lady, for two or three years, has had severe digestive disturbances; for the last six months she had repeated attacks of uneasiness and tenderness in region of head of the pancreas, and during this time she had developed an ascites and a continuous jaundice, with much loss of weight. In fact, the history is one of malignancy in the pylorus or head of the pancreas. An operation revealed a distended gall-bladder and dilated common duct; the head of the pancreas was much enlarged and hardened; there were no stones to be found. The pancreatic enlargement had completely closed the duodenal opening of the common duct. A cholecystenterostomy was performed. The symptoms disappeared, and up to this time, one year later, have not recurred.

This was a case of chronic pancreatitis which involved the ductal opening into the duodenum. I recall another case in which there had been a local peritonitis involving the common duct, the adhesions bending the duct to such an extent that a recurring jaundice extending over a period of years was a feature of the case, more or less pain being present all the time. This case was completely relieved by breaking up the adhesions and straightening out the duct.

The cancerous invasions of the duct in this location are frequently due to some unrecognized benign pathology that has persisted for years, the late manifestations simulating very closely lithogenous obstruction, a diagnostic feature of cancer being a gradual and continuous jaundice when once completely established, differing in this respect from the ballvalve stone action in the common duct. One source of a transient jaundice that may lead to a diagnosis of lithogenous obstructions is a displaced right kidney, the pedicle of which, in its abnormal position, may elbow the common duct and produce a jaundice.

The symptoms of this condition are not

sufficiently typical in all cases to warrant a diagnosis of the exact character of the pathology causing the obstruction. However, the presence of an imprisoned gall-stone in the duct is usually accompanied by sufficient symptoms to indicate its presence, and the discovery of a displaced kidney will point to the probable source of the icterus.

A patient, having escaped the acute septic process of an invasion of the colon bacillus into the deeper structures of the common duct and gall-bladder, may, at a later period, develop symptoms due to the later mechanical effects of this inflammatory process, either in the form of a stricture of common duct, or, if the process has run a chronic course, there may be a cholangitis obliterans, thus I have seen two or three closing the duct. such cases. Drainage of the gall-bladder into the jejunum has relieved them all.

As we learn more of the pathology located so frequently in the duodenum, we are better able to understand some of the obscure symptoms pointing to that locality as their source. Ulcers in the duodenum located near the entrance of the common duct in their healing process may include this opening in the cicatrix and produce a closure of the duct, and thus produce the usual train of symptoms that accompany the closure of the duct from any

cause.

Of much value is the clinical history in these cases, as the symptoms and history are somewhat at variance with that of a stoneobstructed bile-duct.

Appendicitis obliterans has long been recognized, but the same pathology in the common bile-duct is a comparatively recent acquisition to our knowledge in this locality. I have seen a few such cases where, at the time of the operation, the duct rolled under the finger like a tendon, so completely was the normal structure destroyed by the chronic cholangitis.

If the obliterative process is confined to the common duct, which is rare, there will be present a persistent jaundice, the intensity of which will depend on the completeness of the obliteration. With the jaundice will be the usual train of adhesive symptoms in this locality, as gaseous distension of the colon, interference with stomach and intestinal digestion, painful peristalsis, etc.

If the obstruction is located in the cystic duct, and the gall-bladder escapes the usual contraction due to the presence of a cholecystitis, this viscera may continue to manufacture mucus, and if infected (as it usually is) a muco-purulent distension takes place, and a pyriform retention cyst is produced, usually

detectable below the border of the liver in these emaciated patients.

In this condition jaundice is absent, and the patient will have fever, and stomach and intestinal digestive disturbances. These cases are especially liable to recurring attacks of fever, as the absence of bile in the gall-bladder robs nature of one of the most efficient and inhibiting bactericidal fluids. These are fit cases for a cholecystectomy, as drainage of the gall-bladder is too uncertain in its curative effects, the opening either refusing to close, or, if it does close, the symptoms are renewed.

Stricture is invariably the late manifestation of some previous pathology, as a healed ulcer, or from stone pressure. These strictures may be complete or partial, extending for only a few lines to an inch or more along duct. The symptoms vary according to the situation of the obstruction and condition of the adjoining structures and organs.

The growths leading to an obstruction of the bile-ducts are of the same character as those found in other parts of the abdomen, the malignant neoplasms predominating, and giving rise to a train of symptoms hard to diagnose early from a ball-valve stone in the common duct, a characteristic feature of the jaundice produced by a malignant growth being, when once well established, intense and persistent, the patient showing more severe and early constitutional effects in the malig

nant cases.

Where the complete obstruction of the duct is the outcome of a long-impacted stone

resulting in a cancer, the diagnosis of the latter is extremely difficult prior to operation. Cancerous obstruction occurs most frequently in the lower portion of the common duct, the location also of most lithogenous obstructions.

In determining the existence of an obstruction, its location, extent and character at time of operating, I have for fourteen years resorted to hydrostatic pressure by introducing through an aspirating needle into the gallbladder a saline solution from a moderate height, or if this viscus has been opened, by irrigating directly into the duct.

In cases where the duct is imbedded in a mass of adhesions and has lost its identity, it can be made to stand out distinctly by waterpressure introduced through the gall-bladder, provided the cystic duct is patent; by this same process the patency of the duct, after removal of one or more stones, can be determined, as I have on several occasions run rather a large quantity of saline directly into the duodenum through the gall-bladder, cystic and common ducts. As a means of determining the security of the duct stitching where the opening in this canal is closed by suture, this method is invaluable; disappearing stones and other débris can thus be washed out of the biliary tract. I am sure, if this simple, safe and efficient procedure were carried out more frequently, there would not be so many post-operative biliary fistula or failures to remove the obstruction, nor would so many secondary operations be required.

The following case report I deem worthy of record for various reasons, that will be brought out later, and which, to avoid repetion, I shall omit at present:

Mr. H. S., aged forty-six, white, strong, wellnourished man, sawyer by occupation. On the morning of April 26, 1906, while engaged in "gumming the teeth of a band-sa wover an emery wheel, the wheel burst asunder, one-half of it striking Mr. S. flatwise across the left frontal and superior maxillary bones. The emery wheel above mentioned was fifteen inches in diameter, weighed about eleven pounds, and was revolving at a speed of 1,500 revolutions per minute, which would give an approximate striking energy of 1642+foot pounds, an enormous force, when one stops to think of it. Mr. S. was rendered immediately unconscious by the blow, and was carried to a nearby house, where medical aid was given him. The attending physician, perhaps think

ing the case a hopeless one, simply washed and sutured

the skin wounds of the forehead and cheek, and applied a simple protective dressing. (Unfortunately, the writer has been unable to secure any accurate data regarding the condition of the pulse, respiration, reflexes or sphincters for the twenty-four hours previous to seeing the patient.) There being no noticeable improvement in the condition of the patient throughout the day and night of the 26th, the following day at noon he was placed on a train and conveyed some forty miles to Ashland, where he was placed in the King's Daughters Hospital.

At 7:30 P.M., nearly thirty-six hours after receipt of the injury, the writer saw Mr. S. in consultation with Dr. A. H. Moore, of this city. The conditions noted at this time were as follows: Coma profound; pulse 60, full and bounding; temperature 99.2°; respiration 8 per minute; urine passing involuntarily; reflexes abolished; extremities flaccid, cold and moist. Over the left frontal bone was a large Y-shaped wound extending from the supra-orbital ridge almost

whatever. We next di rected our attention to the orbital contents, and found that, owing to the extensive destruction of the globe, enucleation would be necessary, which was promptly done.

The sutures were next removed from the wound over the os frontis, and wound slightly enlarged for better inspection. As soon as this was done it was plainly evident that the bone had suffered serious injury. Eight fragments, varying in size from 1x 5% inches down to ex inches, were removed, leaving a large irregular opening in the skull, extending into the orbital roof and frontal sinus. Through this large wound the pulpified brain matter exuded in alarming quantities, while hemorrhage

(apparently from superior longitudinal sinus) was exceedingly profuse. After clearing out all clots and broken-down brain tissue there remained a cavity in the frontal region of the brain large enough to admit a full-sized orange, as I could easily sweep my middle and index fiugers around the space from vault to base and from temporal region to falx and as far posteriorly as the pre-central sulcus, without coming into contact with brain matter.

The cranial wound was carefully irrigated with hot normal salt solution and packed with sterile gauze, and a large rubber drainage-tube brought out at the most dependent angle of the wound; a large tube was also carried up through the orbit into the cranial cavity for more efficient drainage. The scalp wound was closed with sutures down to the tube and packing. The wound on the cheek was carefully packed with iodoform gauze and the lower jaw bandaged tightly up against the upper to hold the fragments of the latter in position.

SUBSEQUENT TREATMENT AND COURSE OF CASE.

On the morning following the decompression operation the coma had lessened to some extent; the pulse was 79, and of better volume and frequency; the thermometer registered 990 F., and the respirations had increased to 16 per minute; urine still passing involuntarily.

On the 29th the thermometer stood at 980 F., pulse 79, respirations 16, urine voided involuntarily; mental state considerably improved. On the 30th, pulse 84, temperature 980. Did not rest well. Calomel, gr. iii in broken doses, followed by full dose of magnesium sulphate at 6 A.M.; salts again at 2 P. M., followed by an enema, which was not very effectual. At 11 P. M. bowels moved freely; patient very restless. May 1, 6 P. M., temperature 100.4° F., pulse 88, respiration 18; rested better than usual; urine voided. Dressings changed on second day; wound of cheek free from pus; wound of forehead infected and discharging pus; drainage-tube removed from orbit, as the lid margins were showing slight softening from pressure of the tube. Patient's mental state improving, as he would now respond to questions, although in an unintelligible manner.

There was no motor aphasia, but a very distinct Wernicke's or paraphasia. For instance, after I had impressed upon him my full name, and then requested him to write it, he gave the following:

Dr Geor Williams Wheeling Williams Layme

On inquiring if he had eaten anything, when only the most plain diet had been given, he would say: "Yes, I had frog legs and squirrel for my breakfast this morning." When shown such simple objects as a knife, pencil and the like he was unable to recognize their nature and

uses.

The wound of the frontal region was now discharging very copiously a thin white pus of very offensive odor, and to obviate this the cavity was irrigated twice daily with hot 2 per cent. boracic acid solution followed by packing with a long strip of iodoform gauze saturated with pure balsam peru. This treatment was carried out until the discharge of the patient, June 2, with the exception that as the brain cavity grew smaller and the discharge lessened, dressings were made only once daily.

On May 4, the patient complained of considerable pain in the head; the pulse grew rapid (120) and feeble, and the general condition was not at all favorable. However, under full doses of the bromides the pain soon subsided, and then strychnia was administered to strengthen the pulse and. reduce its frequency, which it did very quickly and permanently.

From this time on until the discharge of the patient there is very little of note to record. The cavity in the frontal lobe gradually filled up until on a level with the skin surface, when epidermization took place, completely covering it over, but leaving a very unsightly disfigurement. The mental and physical state rapidly improved, and on the 22nd of May the patient was allowed to sit up for the first time. Within the next few days he was out of bed, apparently in perfect health, with nothing noticeably wrong mentally, but the persistence of a slight paraphasia.

On May 25 I requested him to write me a short

Dear Sir and Friend: As I am improving in health at present and hope you the same good luck. I will try and answer my promise with you a few days ago.

Well, I hardly know how to begin, only will say about a month ago to-day I happened with a little accident, as you are well aware, at a place near a little place called Charley, in Ky., near Dunmore, Ky. I was gumming a saw and somehow the emery wheel split, and the next thing I knew I was at the hospital up here where I am at now, a place called Ashland. I have been at this place one month to-day. But I will be able to leave in a few days, I think. My home is at Belton, Ky., in Muhlingburg County. I am up here looking up some hickory timber for T. D. & W., of Louisville, Ky.; also other timber of all kinds; will deal in good hickery of any size and lengths.

Well, Doc, I do as one appreciate your hospitality while up here. You bet I want you to be on the lookout all the time. Well, I guess I will close for this time. I will call on you the next time, if I can get you. Yours truly and success, H. SHORT.

The patient was discharged June 2, and went away in perfect condition mentally and physically.

The accompanying photograph and appended letter were sent me shortly after his return home, and show better than any description his mental and physical state:

YOST, KY., June 18, 1906. DR. LAYNE, Ashland, Ky. :

Dear Sir and Friend: This letter leaves me as well and better than when I left Ashland. Hope will find you well and your business all O. K. Doctor, I got in home better then I expected. My head is improving slow all the time. I have had no trouble with it at all. I think my head will be well enough for me to come back in a week or two. But I am aiming to take good care of myself till I get sound and well again. I think I will come back up there this summer and stay all winter.

I

Well, Dock, I will send them pictures soon as I get them. I had them made on my way home. am looking for them now. I will close for this time. I want you to write soon as you get this letter. H. SHORT.

Yours truly,

COMMENTS.

There are several features in connection with this very interesting case that are beyond human comprehension, and I shall place them in the order of their importance:

1. Why was this man not killed by the severe shock of the initial blow at the time of injury?

2. Escaping this fate, was not the extensive destruction of brain tissue, with the thirty-six hours of coma and compression, sufficient to have carried off the ordinary individual?

3. With the severe infection of the cranial cavity present in this case, is it not re

markable that the patient did not die of suppurative meningitis; and owing to the long period of suppuration that no hernia cerebri developed?

4. There is no question in the mind of the writer but that the greater part of the left frontal lobe was entirely destroyed, and if this be the seat of intellectuality, as we are taught, it proves that in some individuals, at least, the opposite side of the brain may compensate for the loss of its fellow. Phelps makes the statement that loss of the prefrontal lobe is always followed by impaired mentality.

Expert Testimony in Insanity.

Dr. William Hirsch, of Cornell University, an eminent alienist, made an address recently before the Boston Society of Medical Jurisprudence on expert testimony and insanity. Dr. Hirsch was one of the experts retained by the prosecution in the recent Thaw trial. He said that if a man deliberately kills another, then tells why he did it, he cannot see why any one should say that the slayer did not know the nature and quality of the act performed. Yet we have the spectacle, the phenomena of two sets of alienists disagreeing. In European countries experts are never retained; they are appointed by the court. There should be in this country as in Europe a partial responsibility, recognized and separate courts for the insane. There are more paranoiacs out of the insane asylums than in them. They are subject to punishment and reward in insane asylums that will deter them from crime. An honest district attorney like the one we have will not go out after a man's life when he is in this plight, but will appeal under the law that says that no man who is incapable of understanding the risk he is running should be put on trial for his life. Paranoiacs who deliberately shoot down people who are enemies are not to be allowed free on the community. Dr. Hirsch continued to the effect that individuals who committed crimes during attacks of. psychical epilepsy were invariably overwhelmed with horror when, on recovering their consciousness and reason, they were informed of the acts they had committed, instead of boasting of their crime and setting themselves up as heroes or modern knights.

E. S. M.

How wofully mistaken is the Delaware, O., Gazette when it says: "The American Medical Association is taking steps to instruct the public regularly and systematically in every-day hygiene. Perhaps this movement will forestall the scheme for a National Health Bureau." Forestall! Bless you, it will aid and further it.