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report of such a case. The contents of the abscess, usually consisting of pus, mucous, or bile, escapes in greater or less quantities from these fistulous openings, and the gall stones are generally eliminated by the same means. The number of gall stones thus passed are sometimes enormous, reaching, as in the case cited by Von Schueppel, six hundred, and in my case, one hundred and thirty. The appearance of calculi is generally preceded by the discharge of pus or bile for several days or weeks. In the case which I report, there was a discharge of pus for nearly two weeks before the first stone made its appearance, and I must confess it was only on the appearance of this stone that a satisfactory diagnosis was arrived at; and this brings us to a consideration of the difficulties attending a correct diagnosis of these cases. In a great majority of cases no satisfactory diagnosis can be arrived at prior to the appearance of the calculi. If the patient has been subject to hepatic colic, or if evidence of gall stones has been found in the stools, we may be guided to a correct diagnosis; but otherwise the most experienced practitioners may be deceived. The prognosis must of necessity be guarded, but usually disfavorable. As to the treatment, the physician must be guided by symptoms and circumstances. I will refer to this part of the subject after I have given you the report of my case.

On the 21st day of June, 1878, I was called to see Mrs. R., whose age at the time was fifty-seven. The following symptoms manifested themselves. Her temperature was about 101, her pulse full and beating at the rate of 120 per minute; her tongue was heavily coated, the skin was dry, and she experienced a great deal of pain in the right inguinal region. She was lying on her back, and stated that it was impossible to lie on either side, especially the right, on account of the pain produced by so doing. She had been sick nine or ten days, previous to my being called. Upon examining the site of pain, I discovered a well-defined tumor in the right side, extending from the lower rib almost to a line with the anterior, superior spinous process of the ilium, and beyond the median line. There was great tenderness on pressure, but no fluctuation could be discovered. It was hard and nodulated, and at first my impression was that I had a malignant disease of the liver to treat, but the tumor had appeared too rapidly for me to be

satisfied with such a diagnosis. I rejected ovarian tumor, either cystic or fibroid, for the same reason. If fibroid its growth would have been shown and there would not have been the same amount of pain and constitutional disturbance; and if cystic, still less would these symptoms have shown themselves. Then, too, the tumor would have been raised out of or lowered into the pelvis, according to the position of the patient, but it was immovable. I excluded malignant ovarian growth for the same reasons. That it was not simply circumscribed peritonitis, I was satisfied from the absence of symptoms peculiar to that disease; still there was some peritonitis present. What was the disease? I confess I was at a loss as to how to diagnose it. In reply to the anxious inquiries of the patient and relatives, I stated that it was some liver trouble, but was not then prepared to state exactly the nature of the disease. I will state here that there was no jaundice present then, nor was there any after, during the whole course of the trouble. I asked permission to bring in some older physician in consultation, which was granted, and after leaving the following prescriptions, I left. I put her on:

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. 3 ss. (16.00 C. C.

SIG. Five drops (0.333 C. C.) in wineglassful of sweetened water every 4 hours.

On the following day I called, bringing with me in consultation Dr. Sloan. Her symptoms were about the same as the preceding day. She had passed a very restless night. After a thorough examination, Dr. Sloan was of the opinion that the disease was malignant and that the liver was involved.

The same plan of treatment was continued, a little morphia being added to relieve pain, I continued visiting the patient twice

a day for several days, when no improvement in the symptoms showing, I was asked to bring Dr. Bowman in consultation. Dr. Bowman was accordingly called, and upon a thorough examination he was satisfied that the trouble was ovarian tumor, and that nothing short of an operation would relieve her. To this the patient decidedly objected, and as the sequel proved, it was well for her that the operation was not undertaken.

On the following day, the 20th day of June, Drs. Bowman, Sloan and myself called upon her, and after a still closer and more thorough examination, we arrived at no nearer a solution of the difficulty than we had before. Each of us was still maintaining our respective theories in reference to the nature of the disease. The same treatment was continued, however, and we concluded to await the results. On the 27th her symptoms became more alarming, and I began to be apprehensive that the case would soon terminate fatally, but upon pressing the tumor I discovered some fluctuation, and I then felt rather confident that I had an abscess of the liver to deal with. I ordered flaxseed poultices to be substituted for the hot cloths she had been using, and on the 29th I had the satisfaction of seeing a yellow patch under the cuticle. I opened the skin and immediately a large quantity of pus made its escape. The relief felt was instant, and her condition began to improve from that time onward. In the course of the next five or six days three or four more openings made their appearance, and for nine days a thin yellow pus continued to flow from these openings before any calculi made their appearance. I was sent for and the stones were shown to me, and I must confess that I was a little startled at the sight of them; not so much on seeing the stones as at the fact of no bile passing out with them if the stones were from the gall bladder, as I have no doubt they were, from the number she subsequently passed. The explanation I discovered after to be in the fact that the cystic duct being open and in a normal condition, the. bile naturally followed that channel, and hence it was no icteric symptoms ever showed themselves in the patient.

About the 9th and 10th of July several more openings appeared from which pus escaped, and at irregular intervals more gall stones. I did not visit the patient very regularly after this date, but I was kept informed as to the progress of the

disease. Fifteen openings appeared in patient's side from first to last, and at one time eight of these were discharging pus and gall stones. About two months ago the last stone was passed, making in all that had been counted about one hundred and thirty. I am satisfied that a great many escaped notice, and it would be safe to estimate the number that were discharged during a period of nearly three years at two hundred. It would be difficult to state the amount of pus that passed during the whole period.

About eight months ago, when all but one opening had healed up, a hard tumor began to be felt in her right breast. This has been constantly growing since until at present it is very large in size, hard and nodulated, with all the appearance of cancer. She attributes its presence to the stoppage of the flow of pus, but I am satisfied it would have appeared if she had never had the hepatic trouble. I have advised an operation for the removal of it, but she does not seem willing to submit to it. About two weeks ago the last fistulous opening closed, and since that time the patient's mind has been more or less troubled and her health not quite as good as it had been. The question naturally arises, whether or not the fistula should have been kept open by surgical means. I am not prepared to say, and I have not been able to obtain much guidance from the authorities I have consulted.

I

From the reports of such cases as I have read, no interference was ever resorted to, but nature was left to take its own course. have, therefore, hesitated about interfering in this case. I should like very much to hear this matter discussed.

A few words on the treatment pursued, and I am done:

Throughout the whole course of the disease, my main reliance was upon nitro-muratic acid. A steady and uniform line of treatment was followed, my aim being to treat the symptoms as they manifested themselves.

In conclusion, I must say that, in the whole range of medical literature, I have not read of a case that presents more points of interest to the practitioner than this one, considering the length of the disease, the comparative good health of the patient during its progress; the amount of pus discharged, the number of calculi, that escaped; the number of fistulous openings that appeared, it certainly is a remarkable case, and I have cheerfully, though imperfectly, reported it to you, I thank you for the kind attention you have given me,

AMPUTATION AT THE KNEE JOINT.

BY R. E. HAUGHTON, M. D.

This operation was performed by Heldanus in 1581. In more modern times it was first executed by Hoin, and others after him, but fell into neglect because of the old fear of entering large joints. Velpeau, the celebrated French surgeon, in 1830 reported a number of successful cases, yet it was neglected. In still more recent times, both American and European surgeons have been advocating it, and the statistics of Markoe, Brinton, Smith, indicate a lessened rate of mortality than in amputation on the thigh. Prof. S. D. Gross states the reasons for making an amputation at the knee, thus:

"First-The stump being longer than in the thigh, amputation is more under the control of the patient, and better able to bear the weight of the body upon an artificial limb, enabling progression without crutches.

"Second-There is no retraction of muscles, and less risk of exposure and exfoliation of bone.

"Third-That pyæmia is much less liable to occur, from the fact that the medullary canal is not opened.

"Fourth-The wound made is not so large as in the limb above, and that statistics show a lower rate of mortality."

In view of the interest which attaches to the best methods, and in view of the risks and accidents which are prone to occur in this operation in the hands of the best operators, we desire to review it, and in the spirit of fair and just criticism, so as to reach the truth. It may be said that it has already passed into acceptance as a legitimate operation, yet the record of its literature shows

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