gall bladder rested, should be drawn together and stitched, to avoid any raw surface being left. In all of these operations I think drying preferable to flushing the abdominal cavity.

We now come to the consideration of another class of cases, which while they are far more serious are fortunately less frequent, namely, those wherein there is an impacted stone in some one of the ducts. If the stone has lodged in the cystic duct, it can be removed without difficulty through the gall bladder by the method just mentioned. In fact, nearly all cases of calculi in the gall bladder present obstruction of the cystic duct, hence, these can scarce be considered as a class by themselves. Lodgment in the hepatic duct is quite rare. I have never seen such a case but a few have been recorded. In such cases the calculus can be reached either through the gall bladder or by incising the hepatic duct and removing the stone.

Lodgment in the common duct is a more frequent occurrence. Mayo Robson says that about 67 per cent. of cases of obstruction of the common duct occur at the duodenal extremity; about 18 per cent. at the upper or hepatic extremity; and 15 per cent. at the middle. portion of the duct.

Up to this point the operation for the removal of gall stones has been comparatively easy and safe, but the moment we attack the common duct, we pass over the line of safety into the region of danger. It is rare that the surgeon is called upon to make a more difficult or dangerous operation than that of choledochotomy, which is an incision into the common duct, the removal of a calculus and the successful closure of the rent through which the stone was removed. The calculus has succeeded in passing the sentinel at the outlet of the gall bladder and has pushed on into the cystic duct. Here it has made its ready escape and fled into the common duct, but has been arrested at the gate-way of the duodenum by the small sphincter muscle situated there. Let us notice what effect this passage and interruption of the stone has had upon the patient. She (three out of five such cases are women) has been conscious of the migration of the calculus since it left the gall bladder. Being a large stone, it has caused much distress while in the cystic duct, there being present vomiting, dull ache and other reflex symptoms just mentioned. As soon as the stone entered the common duct the agonizing gall stone colic began, which is caused by the contracting efforts of the duct to force the stone onward, together with the roughened edges of the calculus scraping along the sides. This attack is long or short, according to the time required in completing the journey through the duct. Uusally the stone is forced to

the duodenal extremity of the tube and there stops, but the great pain does not cease then, because the duct is still making great efforts to rid itself of the offending concretion and so keeps up its contracting spasms. In a few hours these contracting fibres tire and relax; then comes a respite from suffering, but as the call comes for more bile in the intestines, the gall bladder is stimulated, bile flows into the common duct, contraction begins and the pain returns. This process is repeated at intervals of six, twenty-four and fortyeight hours, the pain usually coming on at certain hours with considerable regularity. In a few days the patient becomes juandiced, because there is interruption to the outflow of the bile. The surprise is that the juandice does not come on earlier and become deeper, but that is explained by reason of the gall stone floating up and away from the duodenal outlet during the period of quiescence, thus allowing quite a free escape of bile. Indeed, where this is not the case, a fatal cholemia would ensue very rapidly. How are we to distinguish these recurring attacks, just mentioned, from acute attacks due to the passage of separate individual stones? Very easily; the latter come with no regularity, are usually shorter in duration, and when the pain ceases the patient is perfectly well. There is no dull ache, nausea or vomiting following the pain as in the former. Moreover, in the case of impacted stone, each recurring attack is more severe until it is ushered in with marked chill, followed by high temperature and rapid pulse. But a distinctly distinguishing symptom in this condition is the gradually increasing jaundice with clay colored stools.

Our patient has now come to the point where she is seriously ill. She has days, possibly weeks, in which she has no pain. She even clears up of her jaundice, because of the valve-like action of the stone in the common duct, but it is sure to come on again, the juandice grows deeper, exhaustion is more marked, vomiting frequent and stools clay colored; every new attack runs the temperature a little higher, reaching 104 degrees. What is going to be the outcome? What can be the outcome when eight or ten ounces of so poisonous a substance as bile are force into the general circulation every twenty-four hours? Inevitable death, and it is positively foreshadowed by the foregoing, symptoms. A patient may last from three to eight months in the condition described, and every day nature will be crying out piteously for relief.

There are two difficulties in the operation of choledochotomy: first, to find the stone, as the outlet of the common duct is in the lesser peritoneal cavity, behind the stomach and plyorus, deeply

imbedded in its surroundings by connective tissue, omentum, peritoneum and intestinal adhesions. The second difficulty is the insertion of the sutures to close the rent, through which the stone has been removed. This is best done by passing the sutures, after the Lambert method, before the stone is removed, for the moment the stone is delivered, the outstretched walls of the tube collapse instantly, bile pours out of the incision, presenting almost insurmount able difficulties to a proper closing of the opening. By passing the sutures first, the stone fixes the duct and keeps it distended. The loops of the sutures are pulled out of the way, the incision is made between the sutures, the stone delivered, and then the tightening of the sutures closes the incision at onc.

However, before closing the incision into the duct, the surgeon should make sure that the duct is open, both into the intestine and back into the cystic duct. As it is almost impossible to avoid a slight leakage from the duct incision, it is better to pack around the tube with gauze and then leave drainage; otherwise the leakage and diffusion of bile is almost sure to cause trouble.

It is gratifying to learn how much is being accomplished along surgical lines for the relief of this class of sufferers. Few diseases of a chronic type cause more excruciating agony to the patient than gall stone colic, and any reasonably safe method which promises not only relief but a fairly sure guarantee against return is worthy of our most careful consideration. I am convinced that gall stone surgery soon will stand on the same plane of rational treatment as are ovariotomy and hysterectomy, and that in a short time there will be placed to its credit the relief of thousands of otherwise incurable sufferers.

Examinations for Pneumonia Commission's Physicians.—To inquire into the causes of the alleged increase of pneumonia in New York City, the authorities have appointed a commission of experts, including some of the most eminent medical men in the country. At the Commission's first meeting, it was recommended that physicians be engaged in various cities to collect local data. As these physicians are to be paid for their work by New York City, the Civil Service Commission has passed the word that they must take the Civil Service examinations. As the work is of but temporary character, the remuneration not extravagantly high, and an examination would involve a trip to New York, this action bids fair to nip in the bud the collection of the necessary data and hinder the work of the Pneumonia Commission.

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MORTALITY OF TUBERCULOSIS AND PNEUMONIA.

T

HERE has been considerable discussion throughout the United States of late as to the number of deaths from tuberculosis and from pneumonia. It has been asserted, in a general way, that the number of deaths from tuberculosis was decreasing, whereas the number of deaths from pneumonia was increasing. These statements have been put forward by persons in authority supposedly in possession of the facts, and have been accepted without question.

In no branch of medicine have greater advances been made in the past few years than in etiology. As the knowledge of the causation of disease becomes more definite the knowledge of the prevention of disease should also become more definite. These premises being true, it follows that the death-rate should grow smaller, and expectation of life longer.

It is now believed that both tuberculosis and pneumonia are infectious diseases, the one running a more or less chronic course, the other an acute course. Each is supposed to be due to a certain specific organism. If these statements are facts, then, with the present knowledge of prophylaxis both diseases

should show a diminishing death-rate and not one alone. Any other result would prove either that the general belief was erroneous, or that the medical profession as a profession was not doing its full duty.

Medical statistics, to be of value, must cover considerable areas of population, and considerable periods of time, otherwise the percentage of error vitiates them. The Bureau of the Census has issued a bulletin on “A Discussion of the Vital Statistics of the Twelfth Census." From this bulletin the NORTH AMERICAN has selected the figures on the death-rate for tubérculosis and for pneumonia. The figures cover the eleven years 1890 to 1900 inclusive. The "discussion" accompanying the figures is by Dr. John Shaw Billings.

Tuberculosis. In 1890 the number of deaths per 100,000 of population throughout the United States was 245.4. In 1900 it was 187.3. This is a decided gain, and is undoubtedly due to the tremendous interest that has been aroused throughout the country regarding this dread disease. The improvement has been general throughout the country. Certain cities have been selected and the rate given for each of the eleven years.

Boston, Mass.; Fall River, Mass.; Worcester, Mass; Providence, R. I., and New Haven, Conn., a group of New England cities, show an average annual mortality for the eleven years of 244 per 100,000. Grouping the years 1890, 1891, 1892, 1893, the rate was 272. In 1894, 1895, 1896, the rate was 247. In 1897, 1898, 1899, 1900, the rate was 218.

Jersey City, Newark, and Paterson, N. J.; New York (Manhattan and Bronx), Rochester, and Syracuse, N. Y., and Philadelphia, a group of Middle States cities, show an average annual mortality for the eleven years of 259 per 100,000, grouping the years as above the rates were respectively 292, 252, and 235. Buffalo, Chicago, Cleveland, Milwaukee, and Toledo, a group of Lake cities, show an average annual mortality of 156 per 100,000, grouping by years again the rates were respectively 177, 153, and 142.

Baltimore, Memphis, New Orleans, and Washington, a