contraindications, we almost invariably use general anesthesia. General anesthesia enables the operator to more thoroughly protect the patient from pain, to better guard against accidental septic contamination, to secure a more complete muscular relaxation, to proceed more deliberately, to modify his procedure so as to better adapt it to the needs of the case at hand.

Perusal of the literature shows that in these operations the employment of general anesthesia is in accord with the practice of European and American surgical centers.

By what type of incision is the operator best enabled to perform the repair work which he deems appropriate and necessary?

Large, methodically carried out incisions are infinitely less dangerous than small openings. The latter fail to fully expose the operative field, do not enable the operator to satisfactorily cleanse the joint and do not facilitate the careful repair of the lateral capsular and aponeurotic tears.

The single median vertical incision, unless it is made very long, does not admit of easy manipulation of the fragments. The freshening of the old cicatrized surface on both the upper and lower fragments either with saw or chisel is not easily accomplished through it; it does not admit of easy cleansing of the joint. During kneeling the scar is in the line of pressure, and, therefore, remains tender for an indefinite time. The H-shaped incision has objections. The scar lies directly across the patella.

In operating for fractured patella, I generally employ for the exposure of the parts, a flap having its convexity downwards. The incision commences on a level with the upper margin of the patella, about one inch to one side, from here it passes downwards to a point a little below the apex of the bone, from where it is continued across the limb, and carried to a point corresponding to that from which it started. This incision does not interfere in any way with healing. It is thought that an incision with the convexity downwards better secures the vitality of the flap than one with the convexity upwards.

These convex incisions afford a good exposure of the parts, facilitate the removal of intra- and extra-articular exudates and extravasations, give good access to the bony fragments and allow of careful repair of all capsular pre- and parapatellar tears. If drainage of the peri-articular tissues is necessary it is easily secured. With a longitudinal incision, drainage is somewhat difficult.

Is it advisible in these cases to irrigate the articulation; if so, with what fluid, an antiseptic solution, irritating or non-irritating, or merely a bland, non-irritating, cleansing agent, such as normal salt solution; or is the mere sponging out from the syn ovial cavity of the extravasated liquid and clotted blood, produc tive of the most satisfactory results?

Joint irrigation with irritating antiseptics, such as carbolic acid and bichloride of mercury, we condemn. Any agent acting

as an irritant upon joint endothelium, lowers its resistance to infection, predisposes it to inflammation. In flushings or irrigations of the joint cavities with normal salt solution, which solution is in itself unobjectionable, we fail to see much value. what advantage can it be to waterlog the tissues?

Of

In arthrotomy for fractured patella we do not irrigate either the joint or the surrounding tissues. All liquid and clotted blood are removed by gauze swabs mounted on artery forceps. The swabbing is done with great care, the object being to minimize the trauma inflicted. Scrupulous care is taken to keep the fingers out of the articular cavity. In formulating our conclusion we repeat that though we are aware that many clinicians, for instance Ranzi, etc., prefer irrigation of the articular cavity to sponging of the articulation, we urge the discarding of joint irrigation and firmly advise dry sponging of the joint. Dry sponging for the removal of liquid and clotted blood from the articular cavity is in these cases productive of more satisfactory results. The subquadricepital synovial cul-de-sac is not to be overlooked, and all liquid and clotted blood therein contained must be removed.

Should non-absorbable or absorbable suture material be used? Are there any valid reasons for discarding non-absorbable suture material?

We refer here only to buried or irremovable suture material. If the suture material be so inserted as to be removable, once organic reunion of the divided tissues has taken place, it matters little (owing to the removability of the suture material) whether absorbable or non-absorbable material be employed.

In fractures of the patella it is not necessary that the fragments be held together with great firmness. Mere apposition is ample. Forcible tying of metallic sutures to some extent defeats its own purpose, as a suture drawn tight can cause in a bone, as well as in other tissues, a local pressure necrosis and absorption.

We consider it unwise to abandon non-absorbable suture material permanently in the articulation or in the peri-articular tissues, because:

a. Clinical observation has shown that metallic sutures frequently irritate the tissues, lower their vitality, increase chances of infection, and may require subsequent removal. In longitudinal suturing of bone, the twisted ends of the suture being almost immediately subcutaneous, kneeling is painful. To avoid this postoperative annoyance some operators perform transverse suturing of the patella.

b. Metallic sutures may become loosened, may break, and fragments escape into the articular cavity by which they are poorly tolerated.

c. The embedding of wire sutures in the patella does not add. to the solidity of the patella.

d. Non-absorbable sutures, be they inserted transversely or sagitally, cannot be considered permanent splints.

Von Brunn as a result of his investigations came to the following conclusions:

I. Silver wire has not sufficient resistance to guarantee bony union of the fragments.

2. Even when the fragments are healed together the wire may break.

3. Parts of the broken wire may wander into the articulation or into the peri-articular tissues and can excite disturbances at point of lodgment. It has been claimed by Thiem, etc., that metallic sutures suggestively hinder, in some patients, the cure of the subjective troubles.

Shall completely detached bony fragments be removed? If completely detached bony fragments be present, their removal is one of the essential steps of the operation. It has been repeatedly done, and satisfactory results have ensued. The escape into the articulation of completely detached patellar fragments and their non-removal therefrom leads to all the functional and anatomical articular disturbances inseparably associated with mobile foreign joint bodies.

Shall the periarticular tissues be drained? In order to allow the escape of excessive wound secretions, many clinicians, Hackenbruch and others, though they did not resort to tube or gauze drainage of the peri-articular tissues, always left the ends of the skin incision open. It did not unfavorably influence the ultimate results. In clean cases subcutaneous drainage is needless. Its employment serves no useful purpose. It retards the healing of the skin wound. Why complicate an operative procedure by a useless step?

Shall the articular cavity be drained? In simple fractures, no. In compound fractures, yes. Articular drainage should be discontinued as soon as the surgeon's fears as to the development of a suppurative arthritis have been dispelled.

The modern tendency is to employ drainage only in the presence of absolute indications, and to discard it when in doubt as to its utility in the case at hand. When unneeded, drainage instead of contributing to rapid aseptic healing has a tendency to act as an irritant. In the etiology of inflammation, irritants are considered predisposing and exciting factors.

What should be the nature and the duration of the postoperative treatment? As yet the practice of the different operators as to nature and duration of post-operative treatment is most dissimilar. We proceed as follows: Immediately after the operative procedure and the application of the protective dressing to the wound and while the patient is still anesthetized, moulded plaster of Paris splint is applied to the injured extremity. This splint should be amply padded, should cover the posterior and lateral surfaces of the limb and should extend from about 10

cm. above the external malleolus to the gluteal fold. The object of this splint is to immobilize the extremity in the position of full extension of the leg on the thigh, and of slight flexion of the thigh on the abdomen. The slight flexion of the thigh on the pelvis has for its purpose the relaxation of the rectus femoris muscle. During the patient's confinement to bed attention must be given to the heel and to the toes. So as to avoid the development of a pressure-sore upon former, the heel should be protected by a doughnut pad or other means. By the use of a "cradle" the toes will not be subjected to the weight of the bedclothes and talipes decubitus will not ensue. In the absence of a marked elevation of temperature, or intense pain, of saturation of the dressings, the protective gauze dressings on the joint remain undisturbed for from ten to fifteen days, then, if indicated, the removable sutures are ablated. The immobilizing splint is kept in position for about a month.

As to the duration of immobilization, the practice of the various operators is far from being in accord.

The first motions of the patella should be lateral motions. We do not begin flexion of the leg upon the thigh previous to the expiration of one month from the day of the operation. The first attempts at flexion should be cautiously made. With use, the range of motion gradually increases; in many cases the restoration of joint function is complete. When flexion to a right angle has been recovered, the patient is discharged from further observation.

Suit Following Operation.-The New York Hospital has been made defendant in a suit brought by Miss Mary E. Gamble to recover $50,000, on the ground that an operation performed without her consent has crippled her right arm. The hospital's defense is that the patient did consent to the operation, that this was skilfully performed by a competent surgeon, and that following it she received the best of care.

-Medical Record.

a

Good News From Chicago.-Our friends in Chicago seem to be reaping a very full share of the crop of prosperity that has recently come to homœopathy in this country. Notice has already been given of the donation of $75,000 for a nurses' home for the Hahnemann Hospital and of an additional $30,000 for general hospital purposes. Mrs. Anna W. Phelps has recently presented to the hospital a site for a new building as memorial to her late husband, E. M. Phelps. The property extends from Prairie to Forest Avenues and is estimated to be valued at about $65,000. We are also told that the hospital and college have now at their command over $500,000, with hopes of still more. With this they will build the new college and hospital, and still have a considerable amount for endowment purposes.

Two new cases of leprosy have recently been reported in the Boston newspapers. One came from_Pawtucket, R. I., to Boston for diagnosis. The other was reported by a Boston physician and was a woman, a native of Sicily, 43 years of age, who had been a resident of Boston for four years. She will be sent, undoubtedly, to the leper colony at Penikese Island. The Rhode Island authorities applied in vain for permission to send their case to the same institution.

GALL-BLADDER DRAINAGE.*

BY CHARLES E. WALTON, M.D., Cincinnati, O.

Modern geographical and surgical exploration are antipodal. The former has discovered the North Pole and is now busy in searching for the South Pole. The latter has solved most of the problems of the South Pole of the abdomen, and is engaged now in solving those of its North Pole. Every abdominal surgeon is engaged in this work. The stomach and duodenum, the pancreas, the gall-bladder and bile ducts, are the special objects of investigation. For the purpose of this paper we will consider gallbladder operations.

It is a safe surgical dictum to spare every organ that can be made to perform its function. This applies to the much attacked foreskin, except for Hebraic considerations.

It does not follow that because a deer has no gall-bladder, that a human being is no worse off than a deer if it is removed. The deer cannot miss what it never had. The human body must adjust itself to the absence of what it should normally possess.

Better no gall-bladder than a diseased one, but better a halfbladder in good working order than none. Its action as a compression chamber regulating the bile flow makes the gall bladder a desirable organ even though it can be dispensed with when necessary.

A gangrenous, or cancerous, bladder should be removed, or one filled with pultaceous bile with a hopelessly impaired mucous membrane. But when possible the bladder should be saved. A mucous membrane has strong reproductive power when relieved of a permanent irritation. Relieved of stones, or impaired bile it soon returns to its normal function, if given time and opportunity. The frequent association of gall-stones and cancer of the head of the pancreas leads us to the early removal of the stones as a more than possible cause of the cancer. The restoration of a normal mucous membrane removes the probable formation of stones.

An inflamed bladder, with its impaired bile is very like an abscess in any part of the body. It calls for opening and drainage. Under drainage the mucous membrane of the cystic duct, congested even to the point of occlusion, frequently resumes its normal thickness, and patulency is restored.

Two recent cases are instructively illustrative of the value of drainage.

A young woman, that is, problematically young, as she was twenty-eight and unmarried, had been treated for five years for gall-bladder disease. There were frequent attacks of severe pain. followed by jaundice. Diagnosis, gall-stone. Though repeatedly urged to have an operation, she refused. Finally, becoming incapacitated for work, she consented. A small bladder was found. filled with grumous bile. There were no stones. The mucous

* Read before the Homœopathic Medical Society of Ohio, May, 1911.