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The conclusions of Mr. R. Morison (British Medical Journal, Nov. 3, 1894) in this regard are as follows:

A pouch exists below the right lobe of the liver and gall-bladder, separated from the general peritoneal cavity by natural barriers. This pouch can be efficiently drained through an opening in the parietes near the lower end of the kidney. A transverse is better than a vertical incision in operating for gallstones; less likely to be followed by ventral hernia, and giving free access. Biliary fistula results from operations for gall-stones in a considerable percentage of cases in which the gall-bladder has been attached by sutures to the parietes. The method of attachment has little to do with this result, and it may follow when the ducts are patent. The gall-bladder and ducts may safely be allowed to empty into the pouch described, if it is properly drained. The gallbladder should never, except when suppurating, be stitched to the abdominal wall. If the pouch is properly drained, (a) when the gall-bladder is distended the opening in it should be closed by sutures and the viscus returned into the abdominal cavity, and the drain left until the certainty of its successful closing is complete; (b) when the gall-bladder is shrunken and there is difficulty in closing the opening made in it, it may be returned unclosed; (c) when a stone is impacted in the cystic duct and evades all ordinary efforts to remove it, the gall-bladder should be excised and the duct ligatured after removing the stone in it; (d) when a stone is impacted in the common duct, the duct is incised, and after the stone or stones are removed the opening may be left unclosed if there is any difficulty in applying a satisfactory suture.

I should say, however, that before the gall-bladder is united with the duodenum or bowel the permeability of the cystic and common ducts should be tested. This can be done in one of two ways-catheterization, or by forcing water through the ducts. Catheterization should not be persisted in too long while operating, thus losing valuable time, but the water test is always at hand and can very readily be practiced. Should the cystic duct be found obstructed with a stone, it can usually be removed via incision in the gall-bladder, or may even be removed from the first portion of the common duct through the incised gall bladder. Should, however, the obstruction be in the common duct and not returnable to the gall-bladder or easily pushed on towards the duodenum, several procedures have been recommended and tried, such as crushing with forceps, piercing the gall-stones with needles, or making an incision over the impacted gall-stone and removing it. Each of these has its objections. The crushing with forceps I have already mentioned, and the needling I should say is more dangerous than the incision, and the incision has proved more dangerous than doing Murphy's operation of uniting the gall-bladder with the duodenum. But some of these cases of obstruction to the common duct have also a contracted gall-bladder where a button cannot be applied. In this connection allow me to report a case.

Rev. Mr. A was in charge of Dr. H. H. Chown, of Winnipeg,

with whom I was associated at the operation. Upon opening the abdomen we found a contracted gall-bladder and an obstruction of both the cystic and the common ducts. We incised the gall bladder, removed the stones from it, and through the same incision removed the stones from the cystic duct, and had to desist operating on account of the condition of our patient. We established drainage to the external wound. The patient improved; jaundice disappeared; the wound in the abdomen would close for a time, and a considerable quantity of bile would accumulate in the peritoneal pouch described by Mr. Morison, when this would have to be reopened and the patient would get about again. The constant discharge of bile from the side proved such a nuisance that we determined to overcome the obstruction in the common duct, and this we did by incision and drainage. Patient is now well, as reported by Chown.

This is a case where it would have been utterly impossible to apply a button, and where the only operative procedure was incision and drainage, as we carried it out. It is not yet settled whether it is preferable in an obstructed common duct to apply Murphy's button or to do a cholecystostomy and subsequently deal with the stone in the common duct. In a number of cases that are urgent, that which saves the patient from the most impending danger ought to be done, and this not infrequently is a cholecystostomy to relieve jaundice. We know that bile can escape externally for a considerable length of time without very much danger to the life of the patient. CholecystOstomy will give an opportunity to improve and to be in a better position for a subsequent operation, when cholecystduodenostomy or cholecystenterostomy may be selected. During this period of improvement after a cholecystostomy, some means may be devised by which a subsequent operation may be obviated.

Cholecystectomy, or a total removal of the gall-bladder, has but a limited sphere in the surgery of the gall-bladder. It is indicated in cancer of the gall-bladder which has not yet extended to liver tissue or when the patient is not much constitutionally affected. It is suitable gangrene of the gall-bladder or in cicatricial obstruction of the cystic duct.

Before closing these remarks I wish to enter a plea for early operation for biliary calculi. The most difficult cases are those which have been neglected. Those who have suffered attack after attack of biliary colic, or who have had jaundice for a considerable period, even months, come to us with a contracted gall-bladder and with obstructed cystic and common ducts, which in the early part of their history could very easily have been dealt with by a cholecystostomy.

AINHUM.

BY A. H. OHMANN-DUMESNIL,

Professor of Dermatology and Syphilology in the Marion-Sims College of Medicine, of St. Louis.

This condition is one of more than ordinary interest, and, whilst it is looked upon as comparatively rare, the number of cases reported in recent years would go to prove that, as in the case of many other pathological conditions, increased knowledge and more careful observation give a new aspect to statistical facts. The trouble, however, is far from being common. It appears to be pretty well disseminated, if we take into consideration the various localities in which it has been observed by competent medical men. Beginning east and going westwardly, we find that it is by no means uncommon to meet with ainhum in India, not only about Calcutta and Bombay but in the interior. Many cases have been reported, and many more unreported cases have been seen, as I have learned from eye-witnesses. Ceylon is also the habitat of the trouble, as well as China. In Polynesia a number of cases have been observed. A few cases have been reported from Europe, but they appear to have been imported, hence we cannot say that ainhum occurs there. Egypt has furnished some cases occurring at Cairo and Suez, whilst it is prevalent on the west coast of Africa, in the South African Republic, and in the interior. The island of Madagascar furnishes its quota of cases. Coming westwardly, we find the disease occurring in the islands of Trinidad and St. Thomas, and there can be little doubt that all of the other islands of the West Indies group and of the Caribbean Sea would furnish more if carefully searched. In South America, Brazil has furnished the largest number of cases, but as observation becomes more particularly directed to the condition, there is no doubt that it will be found affecting the natives of all the South American countries. In North America cases have been observed in Canada, North Carolina, and Pennsylvania, in natives of North Carolina, in Louisiana, and in the District of Columbia.

Of course, this hasty sketch of the known geographical distribution will only give a faint idea of the dissemination of ainhum, and there is no doubt whatever that it occurs in many other countries whose inhabitants have not come under medical observation or upon which no reports have been made, either by reason of lack of interest or of ignorance of the disease.

In a consideration of the occurrence of the disease it would seem that there must exist some racial peculiarities which lead to a certain amount of predisposition to the process. Thus, there is no record of its occurrence in Caucasians, whereas it has been observed in Arabs, Hindus, Mussulmans, Mongolians, Negroes, West Indians, and Sandwich Islanders. This would go to show that these individuals are members of races which possess a susceptibility to the disease.

The frequency of the disease is much greater than is supposed by many who either have had no opportunities to observe or who have not carefully read the known statistics of the disease. It is perhaps in India that the best observations have been made in this respect by British surgeons stationed at various points. Their reports show, a comparatively common frequency when we take into consideration the very few cases which have been reported. The fact that the races in whom ainhum occurs are composed of individuals who are seldom seen by medical men, or who do not care to seek medical advice, may account in part for this paucity of records of cases. In addition to this, the fact that attention is generally directed to some more serious condition may further explain why records are so few. There is no doubt whatever that, as medical men become better acquainted with the trouble and come into closer contact with the races affected more cases will be observed and it will finally occupy its true place in the statistical literature of dermic diseases.

by it,

If we examine the combined statistical tables of the American

Dermatological Association, extending from July 1, 1877, to January I, 1893, published in the Transactions for 1894, we find that out of a total of 204,866 cases of skin diseases observed by the members, not one case of ainhum is reported. D. G. Crawford states that in the Indian hospitals one case occurs in every 2,500 surgical cases. Different authors have described many cases, but none of them seems to have taken any pains to estimate the comparative frequency of the affection. C. E. Gooding, of Barbadoes, W. I., in a letter to Dr. Francis J. Sheperd, states that out of a total of 25,000 indoor patients there were only fifteen cases of ainhum. He saw twelve cases in his private practice (total number of patients unknown). To give a record of the number of cases seen by private observers would take up too much space and would prove of little value in regard to the question of frequency, as the majority have neither kept an account of the total number of patients seen by them nor have they paid any particular attention to the matter of not permitting cases of ainhum to escape being recorded.

Ainhum is a peculiar process, chiefly confined to the toes, ending by amputation of those members. The name "ainhum" or "ainham"

means "to saw," in the tongue of the natives of Brazil. It is known by a number of other names, such as "gafeira" by the Portuguese, "sukha pakla" (dry gangrene) by the Hindus, and "ayun" by the Nagôs. The term "guijila" or "quigila" is more particularly applied to the trouble when it occurs in lepers. The Jêjés designate the disease under the term "gudurum," whilst in the island of Nossi-bé near Madagascar the name is "faddiditi." However, the name ainhum, which was applied by J. F. Da Silva Lima in 1867, is the one which has been universally adopted in deference to his choice, as he published the first complete account of it.

The localities principally affected by ainhum are the little toe, and the other toes; the fingers being but seldom the seat of the pro

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cess, and, in such cases as have been reported, it is a question as to whether they were not in reality cases of sclerodactylie or scleroderma. The same objection has been brought forward in regard to cases reported as affecting the arm or leg. Be this as it may, there exists no doubt whatever in regard to the toes. Here the first manifestation shows itself as a constriction of the integument at the joint between the metatarsal bone and proximal phalanx, or at that between either of the phalanges. So far as I have been able to determine, it occurs most frequently between the proximal phalanx and the metatarsal bone. The slight constriction, which presents the appearance of having been produced by a string, becomes deeper and deeper until quite a marked sulcus is produced, as shown in Figs. 1 and 2. As may be seen by the illustrations, the distal phalanx appears rather

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