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case which calls for radical treatment at the beginning. You may be sure of this, that inflamed piles will cause the same kind of spasm of the sphincter ani that an inflamed cornea causes about the eye. With a child who has inflammation of the cornea or any other part about the eye, there will be vigorous spasm, so that you cannot separate the eyelids unless you anæsthetize the child or use considerable force. The spasm of the sphincter ani is always painful, but in the case of inflamed piles there is another feature which is important. The hemorrhoidal veins pass not merely between the mucous membrane and skin of the anus and the muscular coat of the rectum, but also between the fibres of the sphincter muscle; spasm of the sphincter, therefore, causes pressure on the veins and distention of the piles, and this again causes increased spasm of the sphincter, the two phenomena reacting on each other. In this engorged and inflamed condition, what is to be done? If the engorgement be apparently the most prominent feature, you can tap the hemorrhoidal tumors and let the blood escape. You must not do this too freely, or you will invite secondary hemorrhage. If, on the other hand, the spasm seems to be the prominent feature, the sphincter must be vigorously stretched, so as to paralyze it.

Here appears to be an inflamed and gangrenous condition of affairs. This was represented to me as a case of acute inflammation, but I do not find the indications of very acute inflammation, and so I shall treat it in a different way from that which I have just been describing to you. On examining the rectum with a Sims speculum, I find a tumor which was evidently originally a hemorrhoid, but it feels hard, and on puncture the blood does not gush out, as it would from a distended vein there has evidently been an organization of the hemorrhoid into connective tissue.

I think we will be pursuing the wisest course by simply stretching the sphincter to-day, and then endeavoring to build up the patient's strength and watching him carefully, using fomentations to get a line of demarcation between the living tissue and the gangrenous portion of the pile, and then, in a week or so, we will perform the radical operation of removing the tumor. I should not be at all surprised if after four or five days very much of the present inflammation would have subsided, leaving simply the chronic condition. His sphincter will be paralyzed for two or three days, during which time he will get a large amount of relief from the necessary local rest. We will use suppositories containing morphine enough to control pain, a litle ergot for its effect on the vessels, and some antiseptic in addition, such as iodoform or aristol.

OPERATION FOR OCCLUSION OF THE CYSTIC DUCT, WITH CALCULI IN THE GALL-BLADDER.

CLINICAL LECTURE DELIVERED AT THE SOUTHERN MEDICAL COLLEGE, ATLANTA,

GEORGIA.

BY J. MCFADDEN GASTON, M.D.,

Professor of the Principles and Practice of Surgery, Southern Medical College, Atlanta.

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GENTLEMEN, The patient who comes before you to-day is the widow of a physician. Mrs. K., as you will see, is a white woman, about fifty years old, but little emaciated, of whose previous sufferings the family attendant, Dr. Garrett, furnishes a brief account. He has attended her at her home, near Austell, in this State, at various times within the past four years, for hepatic colic and jaundice. Eventually there appeared an enlargement, with tenderness upon pressure, below the points of the ribs on the right side, and she complained of acute pains at times in this region.

Upon examination of her case yesterday, when she arrived in this city, I learned that the attacks from which she had suffered formerly had been less frequent of late, and not followed by any discoloration of the skin within the past twelve months. It was also learned that her fecal evacuations, which had for two years prior to the last year been clay-colored, had resumed their natural appearance. But there was persistent torpor of the bowels, requiring frequent resort to purgatives of an active nature.

When my attention was directed to the right hypochondriac region, I found a very perceptible enlargement of the liver, extending below the points of the false ribs, and by palpation I detected an indurated mass at the lower margin of the liver, which was quite movable. The outline was rather globular below, but extended upward beneath the liver, and inclined to the right when the patient turned upon her right side, and towards the median line when she turned upon her left side. When she lay upon her back the indurated mass corresponded to the usual site of the gall-bladder, and could be lifted upward and forward

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FIG. 1.-Topographical relations of the cystic and common bile ducts. Re-drawn by Dr. A. Fiedler.

by the fingers thrust under it. The effect of gravity in this position caused it to drop backward, and to the eye there was no prominence from it when the thighs were flexed upon the body in the dorsal decubitus.

Considering the great mobility of the mass, with the absence of jaundice recently, there were some grounds for suspecting that it might be a floating kidney, and a colleague who made a careful examination of the case spoke of this without any suggestion on my part. But after comparing the indications for a diagnosis of floating kidney with the points observed in this patient, we both concluded that the preponderance of evidence was in favor of an obstructed gall-bladder with retained biliary calculi, and this is the diagnosis upon which I shall operate in this case.

It may be stated in advance that I do not expect to find the common bile-duct obstructed by gall-stones, as the bile is finding its way into the alimentary canal, as indicated by its presence in the evacuations. It is clear that an impediment of some kind exists in the cystic duct, as the contents of the gall-bladder are evidently confined in that viscus, and it is most likely that biliary calculi will be found in it. You perceive from the drawing on the wall before you that, with the relations of the cystic and common bile-ducts, the duct connecting with the gallbladder may be entirely occluded, while that leading directly from the liver to the duodenum may be free from obstruction. (See Fig. 1.)

The procedure in this case is entirely different from that which would be requisite for the relief of occlusion of the common duct. The latter being unable to convey the bile into the intestinal canal, while it flows freely into the gall-bladder from the hepatic ducts, calls for a communication to be effected by attaching the gall-bladder to the duodenum or some portion of the small intestine. Various operations have been resorted to for this purpose, based upon a series of experiments made upon dogs, by me, nine years ago, with a view to demonstrate the feasibility of effecting an anastomosis of the gall-bladder with the duodenum or the upper portion of the small intestine. It matters not whether an opening is made by my process or by some other, so that the bile is given an outlet from the gall-bladder directly into the intestinal canal, and thus plays its rôle in intestinal digestion. Relief is thus afforded to the colæmia which is poisoning from the presence of bile throughout the system, and which is shown by jaundice in cases of biliary obstruction.

Our patient will not require to have an operation of this nature, but simply to have the contents of the sac removed, and to have the

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