NLM005549612 REPRINTED FROM THE "MONTREAL MEDICAL JOURNAL." A RETROSPECT OF SURGERY. JANUARY 1886-JANUARY 1890. PREPARED BY FRANCIS J. ^HEPHERD, M.D., CM., Surgeon to the Montreal General Hospital; Professor of Anatomy and Lecturer on Operative Surgery, McGill University. MONTREAL: GAZETTE PRINTING- COMPANY. 1890. V Wo 5548r l8

92 Surgery of.........1,89, 2th, 240 " Influence of Antiseptics on. ■ 149 " Suppuration of, Treated by Drainage................ H Lanolin in Skin Diseases............. 54 Laparotomy for Gall-Stones.......... 106 " " Obstruction of Intes- „ T t^es............... 142 Intussusception......200 Results of, in Intestinal Obstruction............ 156 or Enterostomy.........15(5 INDEX. V Leucocythsemia, Splenotomy for..... 93 Ligature of Carotid................... 144 Lip, Cancer of........................ 51 Lister's (Sir Joseph) New Antiseptic Dressing..........................256 Liver, Hydatids of........ .....108,253 " Resection of Left Lobe........143 " Surgery of...............250, 253 Lithotomy....................... .... 17 " Renal...................... 9 " Suprapubic ........... .... 13 Lumbar, Cholecystotomy............. 25." " Oolotomy....................215 Lung, Abscess of..................164, 165 Meningeal Hemorrhage, Trephining ... in..............................58, 151 Mishaps from Use of Aspirator.......209 Muslin Plasters in Skin Diseases..... 55 Naso-pharyngeal Tumours, Removal ot, by Operation.................... 199 Neoplasms, Return of Extirpated ... 134 Nephralgia, Division of Capsule of Kidney for Kelief of............. 240 Nephrectomy........ .............8, 40 for Sarcoma ..... 7 by Combined Abdominal and Lumbar Sections. 9 Nephro-Lithotomy................. 10 " " after Nephrectomy 10 Nephrotomy........................ 10 Nerve, Transplantation of, from Rab- bit to Man........................ 146 Obstruction of Intestines Treated by Laparotomy .................. 142 OEsophagus, Digital Exploration of.. 98 Operations followed by In sanity.,...... 212 Orchitis and Epididymitis, Treatment of..................... ...... 41 Paraplegia, Trephining Spine for Re- lief of........................177 Patella, Fracture of...............21, 43 New Operation for Fracture by Subcutaneous Wire Suture.................... 45 Perforating Typhoid Ulcer, Operative Treatment of.................... 116 Perineal Opening for Cases of confirmed Catheter Life................... 222 Pericarditis, Surgical Treatment of.. 220 Peritoneal Cavity, Removal of a Spoon from............................197 Peritoneum, Physiological Resistance of, to Infection............... 249 Peritonitis, Treatment of Tubercular and Suppurative Peritonitis.. .113, 114, 202 Perityphlitic Abscess ................ 25 Peritypolitis......................202, 203 Permanent Perineal Opening for Cases of Confirmed Catheter Life.....220 Piles, Treatment of by Injection.....171 Pleura, Limits of............. 50 Pleuritic Effusion, Injection of Steri- lized Air in....................... 163 Pneumotomy____ ..... .........96, 197 Primary Operations for Breast Cancer 161 Union after Excision of Hip- Joint ..................191 Prostate, Surgery of Enlarged—142, 150, 221 I Prostate, Enlarged, Galvano-puncture in.........................171 Prostatectomy, a Sequel to Suprapubic Lithotomy ....................222 Pott's Disease, Application of Exten- sion in Vertebral Injuries........198 Pulmonary Abscess, Operative Treat- ment of...........164, 197 ' Cavities, Surgical Treat- ment of...............235 Gangrene Treated by In- cision--- ............ 166 Pyloric Stenosis. Digital Divulsion for ............................... 26 ^t » 17 226 artery and dura mater were found intact, but the dura mater bulged and did not pulsate. It was divided, together with the artery ; a large blood-clot was exposed, and about three ounces of black clot removed by the finger and irrigator. On inserting the finger, the brain was felt to be compressed and the cavity extended forwards and backwards as far as the finger could reach. The pia mater was intact, except at the right frontal lobe, where the cerebral hemisphere was felt to be lacerated and soft. The cavity was well irrigated with carbolic solution (1-40), which came out clear. One catgut suture was introduced into the dura mater and two drainage-tubes inserted into the skull, one going upwards and the other downwards to its base ; the ends were brought out through a hole mode in the lower part of the skin flap. The wound was dressed with carbolized gauze. Next day the patient had a slight fit, confined to the face. On Dec. 16th he was quite rational and began to move the left leg. On Dec. 17th paralysis had gone ; he moved both arm and leg well and was quite sensible. From that date he made an almost un- interrupted recovery. On Feb. 18th he left hospital quite well. Mr. Allingham was of opinion that the case was unique, as it was one of cerebral hemorrhage and not due to hemorrhage between the skull and dura mater. Trephining for Spinal Injury.—At a meeting of the Medical Society of London, held April 8th, 1889, Mr. Herbert Alling- ham (Lancet, April 20th, 1889) read a paper on fracture of the spine treated by trephining. Two cases were reported. The first was injured by a fall of forty feet, and was com- pletely paralyzed, having lost all sensation from a point on a level with the ensiform cartilages. As he did not improve a month after the accident, Mr. Allingham trephined the spine, making an incision about ten inches in length over the 5th, 6th and 7th vertebrae. The muscles were then turned aside and it was seen that the laminae of the 6th vertebra was very badly fractured and depressed. The spinous processes and laminae of the 5th, 6th and 9th were removed with cutting bone forceps, and the cord was exposed for about four inches ; it was rather bruised. The theca was not opened, and the operation 227 took one hour and a half. Sutures were put in the skin only; no deep sutures were used. A large drainage-tube was inserted and antiseptic dressings applied. The wound healed in ten days, and for a while improvement took place, the line of sensa- tion recovering to within an inch of the umbilicus, but since then it had remained stationary. In the second case the patient had fallen from a house and was paralyzed from a line seven inches above the umbilicus six days after the accident. No improve- ment occurring, the spine was trephined, and the spinous pro- cesses and laminae of the 3rd, 4th, 5th and 6th vertebrae were removed. The cord was found crushed, so the dura was opened. In two weeks the wound had healed. The patient died seven months after the accident of bedsores and cystitis ; and at the autopsy the cord was found to be almost divided into two parts, both ends tapering down to a fine point. Mr. Alling- ham drew the following conclusions from these cases : (1) That by trephining, it was evident from these cases that inflammatory ascending changes were prevented. (2) That no bad symptoms followed from the opening of the spinal dura mater and allowing the cerebro-spinal fluid to escape. (3) The operation, though tedious, is not a difficult one to per- form, and does not in any way diminish the chance of recovery. He suggested that in all cases of spinal injury followed by paralysis and loss of sensation, trephining should be done at the end of a week if the patient showed no sign of improvement, so that if symptoms were produced by pressure of blood on dis- placed bone they might be removed before ascending and de- scending changes came on. In the discussion which followed the reading of the paper, Dr. Beevor alluded to the difficulties that arose in consequence of the fact that the anaesthesia began much lower down than the seat of injury would lead one to suppose. He said that the question as to the points in the cord at which the sensory fibres were given off required elucidation. Mr. Shattock has lately been working at this point, and has arrived at fairly definite conclusions as to the origin of the sen- sory nerves. 228 Mr. Wm. Thorburn of Manchester publishes a short note on Spinal Localizations as indicated by spinal injuries in the lumbosacral region. (Brit. Med. Jour., May 4, '89.) From an analysis of a number of cases of spinal injury, certain definite conclusions as to the functions of the various nerve roots have been published in the form of a table. Subdural Division of Posterior Roots of Spinal Nerves.— Mr. W. H. Bennet, at a meeting of the Royal Medical and Chirurgical Society of London, held April 23rd, 1889, read a paper on a case in which acute spasmodic pain in the left lower extremity was completely relieved by subdural division of the posterior roots of certain spinal nerves, all other treatment hav- ing proved useless, and in which death resulted from sudden collapse and cerebral hemorrhage on the twelfth day after opera- tion, at the commencement of apparent convalescence. A laborer, aged 45, was admitted into St. George's Hospital, under Mr. Bennet's care, August 29th, 1888, suffering from acute pain, sometimes spasmodic, in the left leg, apparently due to syphilitic thickening of the tibia of nine years duration. The patient was submitted to the following treatment without relief, viz., (1) the administration of drugs, e.g., iodide of potassium, mercury, anodynes and narcotics ; (2) trephining and linear osteotomy of the thickened tibia; (3) amputation through the knee-joint; (4) stretching of the sciatic nerve ; (5) resection of two inches and a half of the same nerve. By December 8th the patient's condition was much worse ; he had lost strength and was much emaciated, the pain was much worse, the spasms being violent and frequent. By Dec. 23rd it was clear that death must soon ensue if the suffering could not be relieved by some surgical proceeding. Mr. Bennett therefore proposed to lay open the spinal canal, examine the membranes and, if neces- sary, the cord itself over the region of the lumbar enlargement in order to see whether any lesion existed. In the event of this exploration proving negative in result, it was proposed to divide the posterior roots of these spinal nerves, the distribution of which seemed to correspond to the areas over which the pain was felt. The operation was performed Dec. 24th, and the pos- 229 terior roots of the 1st, 3rd, 4th and 5th lumbar, and 1st and 2nd sacral nerves being divided. The patient was entirely relieved of his pain. For two days the patient's condition was critical, and later there was troublesome diarrhoea. By January 3rd the wound had healed, except a small sinus which discharged cerebro-spinal fluid. On the 4th, patient felt discomfort in his head, vomited, became collapsed, and died in a few hours. At the autopsy a large clot was found over the left occipital lobe of the brain. The cord was healthy, but opposite the 7th and 8th dorsal vertebrae was a well-defined thickening of the arachnoid. Prof- Korteweg {Archiv fur Klin. Chir., Hft. 4,'89), in an interesting article on Statistical Results of Amputation of the Breast for Cancer, shows from the tables of Winiwarter, Olde- kop, Sprengel, Hildebrand and Kiister that recurrence is more frequent in cases operated on early, and that the whole length of life after operation is shorter. He explains this by stating that the more malignant the cancer the earlier it is operated on the earlier it returns. In these cases the glands are usually affected early. He states'that the great majority of the cases of return occur in the cicatrix and seldom in the glands of the axilla. In the more malignant and rapid cases the glands are early affected. In the more benign cases, where the glands have not become involved, extirpation of the breast alone has been followed by a comparatively large number of cures. Some years ago, according to statistics, a much larger number of cases existed of simple cancer of the breast without involve- ment of the axillary glands. In 1870, in 60 cases of breast cancer, there were 24 where the axillary glands were not affected ; in two only of the 24 cases was there a permanent cure. At present, in 60 cases, only 10 are without involve- ment of the glands, and out of these, two are permanently cured. He explains this by the fact that now the glands are removed when they are not actually involved but merely inflamed, when formerly they would not have been removed. Hence the result is the same. The 14 additional cases which were regarded as simple mammary cancers would now, because the glands are felt to be slightly enlarged when the axilla is opened, not be re- 230 garded as simple, hence there apparently existed a larger num- ber of cases where the glands were not involved than at present. Again, formerly very severe and advanced cases were not operated on as at present. He urges strongly the thorough removal of the growth locally as well as the axillary glands, and favors early operation in all cases. On the Causes of the Local Recurrence of Cancer after Ex- tirpation of the Mammary Gland.—Dr. Heidenhain of Berlin, at the recent congress of the German Society of Surgery in Berlin, read a paper on the above subject. (La Semaine Midi- cat, May 1, 1889, and Medical News, June 1, 1889.) He had made a histological examination of eighteen cases of cancer of the mammary gland for primary cancer. In all cases in which there had been a recurrence he was able to make out by micros- copical examination that fragments of cancer had remained in the wound after operation. If it is easy to see infiltrated lym- phatic glands, it is not easy to see by the naked eye if the tumor has been completely removed. In the eighteen cases which he examined, he had tried to ascertain whether in the section of the tumor which was in contact with healthy tissues he would find healthy or diseased tissues; on the presence of healthy or diseased tissue would depend the recurrence of the disease. He had in this manner examined several fragments of each tumor ; in twelve cases he had found the tissues infiltrated with epithelial rays, and out of these twelve cases there had been eight recurrences, one death, one patient had disappeared, and two others remain well. In six cases he had found only healthy tissues, and in those six cases up to date the cancer has not re- appeared. In cancer of the breast, the epithelial extensions follow the lymphatic vessels and extend often to the pectoral aponeurosis; it is therefore most important to take away the aponeurotic covering of the pectoral muscle, and even to cut into the muscle so as to be sure that the lymphatic vessels, which cross the aponeurosis perpendicularly, are not infected. Dr. Krister has been in the habit of taking away this aponeu- rosis, because of the bad prognosis presented by cancerous tumors which are adherent to the pectoral aponeurosis. In Von 231 Volkmann's practice, out of sixty-five cases in which the tumor was adherent to the pectoral aponeurosis two were cured, and in all the others the disease has returned. Out of twenty-one cases of the same kind operated on by Krister but a single one is still alive, and she had a return of the trouble ; hence when the tumor is adherent, it is well to take away a good part of the muscle and to clean it thoroughly so as to be sure that the whole growth has been removed. Statistics of Cancer of the Breast.—Dr. Fink of Prague has collected the histories of 194 cases of cancer of the breast treated in Prof. Gussenbauer's wards from 1878 to 1886, tracing after histories to the end of September 1888. He found that at the 41st year the frequency of cancer suddenly increased, slowly rising towards the age of 60 ; 128 of the cases occurred between 40 and 60, 38 between 60 and 80, and 28 between 20 and 40. Activity of the sexual functions had a marked etiological influ- ence, especially in regard to long periods of activity of the functions of the mammary glands ; 72.1 per cent, of all cases had borne children, 62.8 per cent, had suckled them. In 22 per cent., mild or severe inflammatory disease had attacked the affected breast. In only 12.7 per cent, could a clear history of injury or prolonged mechanical irritation be obtained. Direct hereditary predisposition was only substantiated in 8 out of 194 cases. Both mammae were affected with equal frequency. The disease was found to begin in the superior external segment of the breast in a very large majority of the cases—in 104 out of 171 which were carefully and early inspected. In 53 cases, metastases were detected on an average of twenty-five months after the beginning of the disease. These were situated in the pleura, lungs and liver. One hundred and fifty-three of the cases underwent amputation of the breast with clearing out of the axillary glands ; the mortality was 3.3 per cent. Ninety of the cases died of recurrence of the cancer, but Dr. Fink states that most of the women did not apply for relief until the disease was far advanced ; 21.6 per cent, remained free from the disease for two years, and 16 per cent, for three years. The patients who had undergone operation lived seven months longer than those 232 whose breasts were not removed.—{British Medical Journal, June 1, 1889.) Dr. J. Collins Warren, in an article on the Diagnosis and Treatment of Cancer of the Breast {Boston Med. and Surg. Journal, April 11, '89), says that the most important part of the operation for removal of cancer of the breast is the careful dissection of the fascia from the pectoral muscle, for it is in this tissue that capillary lymphatics are concealed, which form hiding places for the outposts of the disease. Careful attention should also be paid to the margin of the pectoral muscle ; not only should the fascia which covers the axilla be dissected off from it, but its lower border should be well freed from fat and connective tissue. The axilla is best opened by a cut through the skin along the edge of the pectoralis, until we come to the edge of the coraco-brachialis ; continuing down on this muscle a short dis- tance with the knife, the skin and superficial fat drop away suffi- ciently to disclose the great vessels lying beneath a thin fascia ; opening this fascia backward along the line we have come exposes the contents of the axilla, and especially the branches of the vessels, which can now be secured. A pyramidal mass of fat is now dissected out, the apex reaching sometimes to the clavicle, the base frequently extending deeply into the subscapular group of muscles. The glands which lie near the clavicle will have to be removed separately, and can best be enucleated from the neighborhood of the vessels by the finger. If they are numerous, the pectoralis can be separated on the line selected for the liga- ture of the axillary artery below the clavicle, and the glands and some of the loose tissue can then be readily removed. Excision of the Scaphoid for Flat-foot.— Mr. Richard Davy {Lancet, April 9th, 1889) says that this static deformity is so commonly met with in debilitated subjects as to suggest many points of consultative interest. He referred to Prof. Ogston's paper read before the Medical Society of London in January, 1884, on Flat-foot and its Cure by Operation, which recom- mended the excision of the astragalo-scaphoid articulation in a wedge-shaped manner and pegging the scaphoid and astragalus together, and stated that Prof. Ogston's paper led him to again 233 investigate the subject. The result was that he found that excision of the scaphoid fulfilled all the requirements necessary and resulted in giving the patient a useful foot. Should any difficulty be experienced in removing the scaphoid, the easiest plan is to chisel the bone in a wedge-shaped form and then care- fully clean the bone out, leaving the cartilage on the head of the untouched as well as the cartilage on the cuneiform bones. The foot is then wrenched inwards so as to press back the astra- galus into place, and make the cartilage of the astragalus touch the cartilages of the cuneiform bones. No little spicula of bone must be left behind between these two opposing sets of cartilages. The utmost cleanliness, of course, should be observed, and after the first stage of inflammation is passed a plaster of Paris splint is advocated. The operation is reserved for advanced and rare forms of club-foot only, where bony deformity and dislocation have occurred, and the distortion cannot be reduced by the manual efforts of the surgeon. Mr. Golding Bird {Lancet, April 9th, 1889), in a paper on Operations on the Tarsus in Confirmed Flat-foot, says there is a class of cases where the arch is so fallen that a convexity rather than a flatness takes its place, due to two tubercles pro- jecting downwards the scaphoid and head of the astragalus ; along with these objective symptoms there is a most wearying and constant aching under the external malleolus. The pain is always present on standing, and after a few hours it becomes a physical impossibility to stand any longer. The continued deep- seated pain the author declares to be due to the fact that, since the arch of the foot is sunken and its piers are now wider apart on the inner side of the foot, a corresponding crowding or mutual pressure of the bony structures forming the outer or supporting edge of the sole takes place, which mere reposition of the foot will not improve. It is in these cases tarsotomy in some form is called for. Mr. Bird operated on four such cases in 1878-80. All were between 12 and 17 years of age. In two the scaphoid bone was removed, and in the other two the scaphoid and head of astragalus. In all the results were good ; all were relieved of pain, but in only one was the arch restored. 234 Inflammation of the Seminal Vesicles.—Every surgeon has met with cases of supposed prostatis and cystitis which resist all treatment. Frequent and painful micturition characterizes these cases, and they go from one surgeon to another seeking relief but not obtaining it. Such cases are always obscure and most commonly follow an attack of gonorrhoea. An explanation of this condition is offered by Mr. Jordan Lloyd. In an article pub- lished in the British Medical Journal of April 20th, 1889, he calls attention to the part played by inflammatory disease of the seminal vesicles in these obscure cases of vesical prostatis one so often meets with. He considers " seminal vesiculitis" analo- gous to Fallopian salpingitis, and states that this is dependent on similar causes. The disease is usually secondary to simple or gonorrhoeal urethritis, the latter constituting the most fre- quent cause. It may also follow simple urethritis due to the passage of a sound, urethral stricture, or coitus with a woman suffering from leucorrhoea. It is also common as a complication of gonorrhoeal epididymitis. The severe type sometimes, but not frequently, ends in suppuration. The tendency is to reso- lution, but if suppuration occur, pus may burrow laterally into the ischio rectal fossa or into the deep circumrectal tissues, or it may escape by the ejaculatory duct, or the abscess may rup- ture into the bladder or rectum. The disease sometimes runs a chronic course, and results in cystic enlargement of the vesicle due to obstruction of the duct. In one of Mr. Jordan's cases the cyst contained ten pints of fluid. The symptoms of " semi- nal vesiculitis " are essentially those characteristic of vesical irritability, inflammation of the neck of the bladder, and of acute prostatitis, with the additional symptoms of almost constant pain- ful erection of the penis. Nocturnal emissions are common, as is also blood in the seminal fluid. Physical examination per rectum reveals the presence of an elongated tumor, situated above the prostate, at the base of the bladder, running obliquely upwards and outwards. The presence and size of this tumor are made more manifest to the exploring finger if a large metallic sound is passed into the bladder and moved from side to side over the tumor. In the acute form, heat, tenderness and swell- 235 ing are felt over the prostate, and if accompanied by the symp- toms of vesical irritability, with no urinary evidence of cystitis, this sign should make the diagnosis certain. Mr. Lloyd recom- mends incision through the perineum rather than through the rectal wall for evacuation of pus when suppuration occurs. He urges digital examination of the rectum in all cases of gonor- rhoea or epididymitis which present vesical symptoms, and believes that in most of such cases this disease will be found. The subject is one of great interest to surgeons, and it is hoped that more light will be thrown on the subject by investi- gations which are sure to follow the publication of Mr. Lloyd's paper. Surgical Treatment of Pulmonary Cavities.—Mr. J. D. Harris (Brit. Med. Jour., May 4, 1889) reports the case of a gentleman, aged 33, who, in 1887, suffered from abscesses of kidney, which broke in four or five places in the loin, and from which he was convalescent, when in March, 1888, he was seized with a rigor, and a pneumonia of the left lung rapidly developed. The pneumonia ran a very unfavorable course, and instead of undergoing resolution, broke down into abscesses. In May he was rapidly emaciating, and had an incessant hacking cough with considerable expectoration, which, towards the end of the month, became foetid. There were now all the physical signs of a cavity of the lung posteriorly, just below the angle of the scapula, on the inner side. By the end of June he was in a highly critical condition and was much run down. Operation was advised and consented to. On July 2nd, without any anaes- thetic, an incision was made through the skin at the lower border of the intercostal space, which ran through the centre of the area of loudest pectoriloquy. An aspirating needle was intro- duced, and pus flowed through the tube ; the tissues were now cut through down to the pleura ; this was then cut through, and following the aspirating needle the lung was incised. A silver tube was introduced and afterwards a large gum-elastic catheter. Considerable discharge came away. On account of the foetor the cavity was daily syringed out with a weak solution of car- bolic acid. The tube was kept in a month, and then a rubber 236 tracheotomy tube was substituted. The patient went on well. His cough ceased and he increased in weight. By Christmas, 1888, only one small renal fistula existed, and the pulmonary fistula had completely healed. Renal Surgery.—The progress of abdominal surgery has been especially marked of late by the increasing number of records of operations on the kidney. Since Mr. Thomas Smith, twenty years ago, advocated the removal of a renal calculus by operation, and Professor Simon proved, after making a series of experiments on dogs, that the removal of one kidney did not necessarily produce acute or chronic disease of its fellow, a whole series of operations on the kidney have come into vogue. There are nephrorrhaphy, or sewing up a floating kidney by its capsule to the parietes ; nephrotomy, or incision of the kidney ; and, lastly, nephrectomy, or removal of the kidney entire. Notwith- standing the truth of Simon's theories, and the encouraging results claimed by several surgeons, nephrectomy must still be considered a very serious undertaking. There is a great difference of opinion amongst the few really experienced operators as to the right manner of performing nephrectomy. Some, like Mr. Lucas, advocate the lumbar, and some, like Mr. Thornton, the abdominal incision. An instructive discussion took place at a meeting of the Royal Medical and Chirurgical Society on April 9th, 1889. Mr. Lucas considered it necessary to estimate for some time the amount of urea ex- creted daily. If this were found to be less than half the normal quantity, then nephrectomy, he maintained, would be a very serious operation. Mr. Knowsley Thornton said that if a large suppurating kidney be treated medically, not surgically, the labor thrown upon its fellow would be possibly greater than that entailed by the operation ; he also quoted one of his cases where both kidneys were diseased, yet when one containing twenty pints of pus was removed, the operation was borne well. To form anything like a correct estimate of the excreting power of the healthy organ in cases where the diseased kidney is not absolutely obstructed is very difficult in actual practice. Dr. Tuchmann's ureter forceps, for temporarily blocking the orifice 237 of one ureter for a time, may prove of service, but many find them difficult to apply. Catheterization of the ureter, practised by Newman of Glasgow, and others, requires much special train- ing. Lastly, physicians, physiologists and chemists have possibly more to discover as to the import of each constituent of the urine. As yet, much in respect to calculating the powers of a healthy kidney when its fellow is diseased is theoretical or empirical. Separation of the Lower Epiphysis of the Femur.—In an interesting article on this somewhat rare accident by Mr. Mayo Robson {Annals of Surgery, Feb. 1889) the meagre description given by surgical authors is alluded to. He does not think the accident is as rare as the standard works on surgery would lead us to believe. In the museum attached to the Yorkshire Medical College two interesting specimens exist. In both, amputation was performed for gangrene. The epiphysis lies with its articular surface forwards, and the lower end of the shaft of the femur (the diaphysis) is directed backwards and presses on the popliteal vessels ; the gastrocremius is attached to the diaphysis. The second specimen was from a primary amputation of the thigh performed by the late Mr. Samuel Hey on account of a com- pound diastasis of the lower epiphysis of the femur. In this case the lower end of the diaphysis projected through the wound in the popliteal space, whilst the epiphysis was directed forwards. Mr. Robson relates a case which came under his own observation. A boy, aged 16, was kicked by a horse on the outer side of the left knee-joint. When admitted to hospital there was consider- able swelling with fluctuation around the knee. The leg and foot were enormously swollen. The foot everted and the leg rolled outwards. No pulsation could be felt in the tibial arteries, the circulation being interrupted by the sharp edge of the lower end of the diaphysis of the femur, which was pressing on the popliteal vessels and making the skin bulge in the popliteal space. The joint was in a state of semi-flexion, and extension was most painful. A marked depression was felt immediately above the patella, beneath which could be felt a movable mass with rounded edges. There was one and a half inches of shortening. Under 238 ether the leg was fully flexed and the parts forced into proper position, then the leg was extended and placed on a Mclntyre splint. Pulsation at once returned in the tibial vessels and the engorged vessels emptied themselves in a few hours. Two months after the leg could be fully flexed and there was no deformity. Mr. Robson mentions two other cases in the practice of his col- leagues, in one of which excision was performed, and in the other a good result followed reduction. In most cases the diagnosis is not difficult. The shortening of from one to two inches, the projection of the lower end of the diaphysis into the popliteal space, the displacement of the epiphysis in the front of the femur, and the interference with the circulation of the leg, form a group of symptoms which are not easily mistaken. The prognosis is serious unless the injury be diagnosed and treated at once ; the dangers arise from the pressure of the lower end of the diaphysis on the popliteal vessels, interfering seriously with the circulation of the leg and producing great oedema or gangrene. In one case reported secondary hemorrhage ensued. Mr. Robson draws attention to the fact that this injury differs from transverse fracture of the lower end of the femur ; in transverse fracture the upper end of the lower fragment projects into the popliteal space, whereas in diastasis the lower end of the upper fragment projects into the space. The treatment is reduction under ether, and if reduction is impossible, excision. I have seen two cases of this accident. In both the accident had occurred several years before, and the patient had good use of the limb. One case under the care of one of my colleagues, the diaphysis had been displaced outwards and caused a remark- able obliquity and deformity of the lower end of the femur which interfered with the lad's progression. The limb was straightened by Macewen's osteotomy. The other case was kindly shown to me by Dr. Elder of Huntingdon. A boy, aged 7, fell and in- jured his leg. When the doctors arrived they found the lower end of the femur projecting through the flesh on the outer side of the popliteal space. They advised amputation, but this being refused, and failing to reduce the protruded bone,1 they sawed off two inches. The boy ultimately did well, and was able to go 239 about in three months. Now (ten years after the accident) he has perfect use of his leg, and the knee has as wide a range of motion as the other. He walks with only a slight limp, and measurement gives some two inches of shortening. Extirpation of Goitre.—Dr. Eugene Hahn (Archivf. Klin. Chir., bd. 36), in a paper on a Method of Partial Removal of Goitre without Tamponade or great loss of Blood, says this method has been carried out on several patients affected with struma. A median incision is made from the incisura jugularis to the cricoid cartilage ; to this is added a lateral incision divid- ing the sterno-hyoid and sterno-thyroid muscles, and then the superficial veins are ligated. In this way the whole gland is exposed. The left upper lobe is then released and lifted forward, the left superior thyroid artery tied ; the inferior thyroid is clamped, and the middle artery tied by first exposing it in lift- ing forwards the gland and then passing a ligature about it. The same is done on the opposite side. After securing these vessels the capsule is divided in its whole extent, avoiding visible veins, and the glandular tissue is drawn forward with a hook. It is thus possible to remove sections of the gland with scissors so as to leave very little behind. There is very little hemor- rhage. The inferior thyroid arteries are only secured by a clamp having a weak spring ; this is done to avoid securing the recurrent nerve in a ligature. If disturbance of speech follows the operation, the clamps can be immediately removed. A weak clamp will control the circulation, but not injure the nerve. The wound should be stuffed with iodoform gauze, the clamps re- moved at the end of twenty-four hours, and secondary sutures applied. Resection of Intestines.—At the meeting of the Edinburgh Medico-Chirurgical Society, held Dec. 5th, 1888, Mr. Cotterill reported a successful case of Resection of a Gangrenous Trans- verse Colon. The patient, a very stout woman, aged 38, had been subject to umbilical hernia for seven years. When seen by Mr. Cotterill she was seven months pregnant. The rupture was a bright red and angry-looking prominence about 14 inches in diameter. The patient vomited coffee-colored fluid mixed 240 with blood. The sac was opened and found to contain a large coil of gangrenous transverse colon, much sloughy omentum and free from faeculent matter. The gangrene appeared to be due, not to strangulation, but to pressure of structures in the sac between the pregnant uterus below and a firm binder which had been worn above. Fifteen inches of colon were cut away and the ends of the gut stitched to the edge of the skin-wound. Three days after the operation the woman gave birth to a child. A few months later an operation was performed for uniting the cut ends of the intestine. The upper end was first ligatured to avoid the escape of faeces. Traction was then made on the two ends until normal gut, covered with peritoneum, protruded suffi- ciently for resection. Instead of using a clamp, the operator passed a piece of thin India-rubber tubing through a small hole in the mesentery and round the gut, fixing it there with a pair of catch-forceps. Four inches of the upper segment of the colon and three of the lower were then cut away with portions of the mesentery. As the lower portion had been unused for five months it was very narrow and hard to join to the upper piece. By careful introduction of over 100 stitches, the ends were brought satisfactorily together. Fine curved needles were used, round, not flattened, and threaded with fine Chinese twisted silk, and the Czerny-Lembert suture was employed. The cut edges of the mesentery were sutured together, and the gut returned to the abdomen. The operation took three hours. On the third day faeces passed. In the two operations 22 inches of intestines were removed. I have space only to refer to the following:— A Successful Case of Immediate Resection of the Intestine for Gangrene, by Robert H. M. Dawbarn, M.D. (New York Medical Record, April 20th, 1889.) Resection of Gangrenous Intestine occurring in Strangu. lated Hernioe, and the Report of a Successful Case : by A. J. McCosh, M.D. (New York Medical Journal, March 16, 1889.) Free Division of the Capsule of the Kidneys for the Relief of Nephralgia.—At the recent meeting of the American Sur- gical Association, held in Washington, May 1889, Dr. McLane 241 Tiffany read a paper on the above subject. The author had suggested this mode of treatment four years ago. The patient was a married woman, aged 49. Had gonorrhoea and syphilis. Three years ago had a severe and sudden pain in right loin. These attacks occurred at regular intervals, the periods becom- ing shorter and pain more severe. Blood was seen at rare intervals ; pain was characteristic from loin to groin increased by exertion. Pressure over right kidney caused severe pain. No tumor could be made out. Kidney calculus was diagnosed and operation was performed January 12th, 1889. The kidney was reached and incised, and a sound passed into its pelvis and a systematic exploration made, but no stone detected. The capsule was freely slit open for three inches and the wound closed. It soon healed. Since the operation no attacks of pain had been felt. In the discussion which followed the reading of the paper, several similar cases were related, several speakers stated that the relief of pain was often only temporary. I very much doubt the existence of these cases of nephralgia. In nearly all these cases a stone would be found if thoroughly searched for.. It has been my misfortune to cut down several times on the kidneys and fail to find a stone. The kidney was always explored in the usual way by sound, needles, and touch. In some of the cases pain was relieved, in others not. In a case where I cut down on the kidney in November, 1888, I failed to find a stone, the pelvis of the kidney was thoroughly explored with a short-beaked sound and the kidney punctured with needles, also handled freely, yet no stone was detected. The patient made a good recovery and was relieved of his pain for a couple of months, but then it returned with renewed violence, utterly incapacitating him from work. I determined to cut down, and if I failed to find a stone, to remove the kidney. The operation was performed in June, 1889, and the kidney carefully examined as before with sound, needles and by palpation; no stone was felt. It was then freely incised, the finger introduced, and at the upper end was felt a hard body encapsuled or rather floating freely in a separate compartment, the intervening tissue was scratched through with 242 the finger-nail, and a stone the size of a marble removed. This could not have been detected with a sound on account of the intervening membrane, and it had escaped the needle explora- tion. It could not be felt at all by the palpation, although the kidney was seized between the finger and thumb and thoroughly examined. I imagine that many so-called cases of nephralgia will, if the kidney be incised, turn out to be cases of calculus. The patient in this case made a good recovery. The Treatment of Scrofulous Glands.—With the advent of aseptic surgery and improved surgical methods, the treatment of scrofulous glands has undergone a great change. Where for- merly glands were left to nature to effect a cure, they are now removed before they have broken down and before the surround- ing tissues are infiltrated with inflammatory products. Formerly the disease lasted for years, ugly sinuses continued discharging, and the scars left were most unsightly. Now, even if sinuses exist, they are opened up, the remains of the altered glands tissue, which is their cause, scraped out with sharp spoons, and the result as a rule is most favorable. Still, in some cases, when the general health of the patient is poor, and.where glands rapidly break down, favorable results do not always follow, the infection spreads from gland to gland, and unless the operation be most complete and radical, the last condition of the patient is worse than the first. Of late much attention has been directed to this subject. There are still surgeons who support the let alone treat- ment, others favor erasion, while others again say that the knife is the only method whereby the disease may be entirely and permanently got rid of. Mr. Fred Treves formerly advocated cautery punc. ture and rest by means of a stiff neck splint ; now he has discarded the cautery puncture, and resorts entirely to the knife when practicable, using the short spoon for the treatment of old sinuses and cavities, which, of course, cannot be excised. The cautery puncture he has entirely discarded, ex- cept to open suppurating glands {Lancet, Sept. 21, 1889). It is most important to remember when speaking of the surgical 243 treatment of tuberculous glands of the neck, that so slight an operation as erasion and scraping out of a gland may be followed by a general infection. Not a few surgeons who have* treated scrofulous glands of the neck will be able to record cases of the kind. It is also well to remember that some cases of tuberculous disease of the glands cannot be treated to a successful conclusion by surgical methods alone. In some cases the general system must be improved by hygienic means, good food, sea air, &c. Drugs seem to have but little effect, though many practitioners seem to rely almost entirely on syrup of the iodide of iron. Whilst treating the glands it is well to look at the original cause, such as a tonsillitis, carious teeth, eczema, nasal trouble, &c. In the Lancet for September 28th and October 5th, Mr. W. Knight Treves has an excellent article on the " Diagnosis and Treatment of Scrofulous Glands." After giving the diagnostic points between simple adenitis, lymphadenoma and scrofulous glands, he goes on to describe the various physical conditions in which scrofulous glands may be found, such as soft elastic gland growth without inflammatory action, hard glands with degener- ated tissue, generally caseous ; suppurating glands, calcareous degeneration, &c. They may be movable or attached ; in fact, scrofulous glands afford infinite variety in their form, course and duration, no two cases being alike. Two requirements are necessary, viz., to establish the general health and to remove thoroughly and completely the local disease. To establish the general health, the patient should be out in all weathers, have the benefit of the sea air, generous diet, wine, iron, cod liver oil, quinine, no worry or fatigue, should sleep in large airy rooms, and wear light warm woollen underclothing. Sea bathing is also advised. As regards drugs, Mr. Treves has no faith in them ; he has seen perchloride of mercury in small doses produce a temporary improvement by reducing surrounding inflammatory deposit and no other drug has done as much. He holds that the local disease can only be got rid of in one way, and that is by mechanical means. The first indication in local treatment is to remove all sources of local irritation, excise tonsils if enlarged, extract decayed teeth, etc. 244 Local treatment to be successful must be thorough. It is a mistake to meddle with scrofulous glands unless we can get the whole thing away. The knife is the only instrument with which diseased glands can be completely removed. Mr. Treves says scooping is chiefly applicable to two condi- tions of diseose, viz., limited superficial gland enlargements, which have uniformly softened, and old fistulous tracts kept open by withered caseated glands. It is also useful in scraping away rotten skin, old inflammatory deposits and cleaning up generally. In removing glands, the skin incisions should be free and gen- erally over the mass. If glands are enlarged beneath the sterno mastoid, an anterior and posterior incision in the line of the muscle is needed, and sometimes two incisions, if the glands be adherent to the vessels. Nothing is more dangerous than trying to extract glands through an insufficient incision. By perseverance, masses of caseous glands can be separated from vessels to which they are adherent. The author does not advocate sewing up the incisions, he prefers to keep the flaps to- gether by sponges or antiseptic wool. Absolute rest must follow the operation; the head must be fixed by sand-bags, and there must be no mastication. For years Mr. Treves has operated on scrofulous glands, sometimes removing as many as one hundred at a sitting, in others excising a mass of glands so large as to threaten suffoca- tion, and yet he has never lost a case. He attributes this suc- cess to never having prematurely closed the wound. The Treatment of Surgical Tuberculosis.—Since the dis- covery of the bacillus of tubercle by Koch, tuberculosis has been classed amongst the infective diseases. The fact that certain individuals are more predisposed to the attacks of bacillus than others does not alter the case, for under certain conditions per- sons not predisposed may yield to the attack of this microbe. At the Paris Congress of 1888, strong resolutions were passed relative to the destruction of all flesh belonging to tuberculous animals, and it expressed a wish that tuberculosis be includad in the sanitary laws of all countries in the world amongst the con- tagious diseases, requiring special prophylactic measures. 245 In the human being when tuberculosis exists, it is important to get rid of it, and so prevent a general infection of the body. In the recent lectures {Lancet, July 27, 1889), by Mr. Howard Marsh, he says that so long as tubercle was re- garded as a constitutional affection with local munifestations, treatment was directed mainly to the constitution, as it was re- garded as useless to remove a mere local manifestation if the essential disease were left behind. With the discovery of the infective nature of tuberculosis and the danger of a limited caseous deposit being a source of total infection for distant organs or for the whole body was impressed on surgeons, and the expediency of the removal of tubercular deposits was dis- cussed. Now, everything was said to depend on micro-organisms, and perhaps this doctrine was carried to greater extent than was warranted by clinical experience. Mr. Howard Marsh, in speaking of hip joint disease, does not believe in the early re- moval of the tubercular focus, but would limit operative inter- ference to the opening of abscesses, and trusts to prolonged rest with extension and fixation and general hygienic precautious. He gives statistics to show that the danger of general and dis- tal tubercular affection from bone and joint disease has been exaggerated, and that it is known to occur in only about five per cent, of all cases of hip disease. M*\ Marsh thinks the ten- dency of tubercular disease of bone is to be self-limited and to undergo recovery, suppuration must not be regarded as de- structive, but as nature's method of getting rid of dead tubercu- lar matter. The mortality in the operation, he says, is twenty per cent., whereas if the joints are left alone it is only five per cent. I think Mr. Marsh has placed the mortality (20 p c.) rather too high. In the hands of skillful antiseptic men it is certainly not, as far as my experience goes, as great as one in five. If we hold these tubercular processes to be due to a distinct micro-organism and that they are infective, it seems to be more logical to remove the focus of infection than to wait for nature to effect a cure. The utility of operative interference in cases where patients cannot afford a prolonged treatment (such cases as those seen in hospital practice), in my opinion does not admit 246 of a doubt. In knee joint affections and affections of the ankle, the results of operative interference have been brilliant. Of course, we must bear in mind that the later the case is left the more serious is the operation necessary for the removal of the disease and the greater the after deformity. Immediate and Remote Results of Operations for Local Tubercular Disease.—At the recent Congress of French Sur- geons, held in Paris during October last {Le Semaine Medi- cale), M. Guyon read a paper on the above subject. He re- corded three cases of tubercular disease of the bladder on which he had operated. One patient had suffered from vesical tuber- cular disease for two years. After operation he made a good recovery, and has had no recurrence. The second case oper- ated on in April, 1887, died two years after, in July, 1889, of suppurative nephritis ; at the autopsy the left kidney was com- pletely destroyed and the right was deeply involved, but no tubercular growths could be found. The third case was oper- ated on in 1888 for vesical mischief, dating back nine month's ; his kidneys were evidently diseased, but, as the patient had painful micturition as many as 100 times during the night, he decided to operate. He operated by the supra-pubic method, scraped and cauterized the ulcer, and greatly relieved the symptoms, so that the patient lived in comfort for a year after- wards. At the autopsy there was not the slightest trace of any return of the tubercular matter. Dr. Guyon said he thought the supra-pubic operation was much the safer. The only case cured was the first, but he believes that he would have cured the others had not the kidney lesion existed. Tubercular dis- ease of the bladder has a very superficial origin (in the mucous membrane) and scraping and application of cautery removes completely the disease. The Treatment of Erysipelas.—According to the Therapeu- tische Monatsch, Sept. 1889, the treatment of erysipelas by germicides is growing in favor. Carbolic acid is too irritating. Koch, of Vienna, uses creolin, his formula is one part of creolin, four of iodoform and ten of lanolin. This is spread on the erysipelatous area, and an inch or two beyond its boundaries, 247 and covered with gutta percha tissue. The theory is that iodine is set free in the combination, and that it, as well as creolin, acts as a germicide ; the results appear to be good.—( Vienna Klin. Woch., 1889, No. 27;) Mechanical Treatment of Erysipelas.—Dr. Wolflers, in an article lately published ( Wiener Klin. Woch., June 6th, 1889) reports two cases in which the mechanical treatment was unsuc- cessful, and three in which it was successful. His treatment 13 to outline the area of the disease with strips of sticking plaster. He has found that the disease will not pass over tl\ese limits. Care should be taken that the strips be closely applied to the skin and the hair should be shaven from the skin. In facial erysipelas it is advisable to shave over the scalp. In a case of erysipelas following ulcer of the arm 7 strips of plaster were placed about the wrist, and as the axillary glands seemed already affected, the second strip was placed over the shoulder and along the sides of the thorax, and the limits were completed by a third strip at the waist. The disease progressed, accompanied by fever, until it reached the sticking plaster, but went no fur- ther, the fever ceased and rapid healing followed. Another case of erysipelas following ulcer of the leg. The bands of plaster were placed around the thigh. The disease quickly extended to the first band, and a very slight inflammation extended beyond it, but did not reach the second band ; fever now disappeared, and the ulcer healed. The third case was one of facial erysip- elas. A strip of plaster around the neck quickly checked the progress of the disease. The two unsuccessful cases consisted of one of gangrenous erysipelas of the thigh and pelvis, death in twenty-four hours ; and a case of erysipelas of the chest, follow- ing an operation for empyema, death in three days. In the same journal for June 14th, Wolflers records seven additional cases, all of which resulted favorably. At a meeting of the Suffolk District Medical Society, Dr. J. C. White said that he could get control over erysipelas generally in three days by simple treatment. Of 100 cases of ordinary facial erysipelas, perhaps three would not yield within three days by simple antiseptic treatment. Dr. White ap- 248 plies, during alternate hours of the day and evening, a mild solution of carbolic acid and alcohol as an evaporating lotion. It is in only very exceptional circumstances that the disease is not under control or has disappeared within forty- eight hours, but it would astonish him if every vestige of the disease had not disappeared in three days. He has treated erysipelas in this way for many years, and has never known it to fail. He speaks of ordinary cutaneous erysipelas only, not the phlegmnaous variety. He uses a formula of acid carbolic crystals, 3p., alcohol and water Siv.—{Boston Medical and Surgical Journal, June 13th, 1889.) In an article on the "Surgical Treatment of Erysipelas in Children," Dr. A Siebert {N.Y. Medical Journal, Oct. 19th, 1889), says that to open inflamed skin by numerous incisions made all over the diseased surface, and then to cover the part with antiseptic lotion, has been practised for some time with moderate success. So has also the injection, hypodermically, of a 2 per cent, solution of acid carbolic into the healthy skin sur- rounding the inflamed part. Kraske's method was the first step in the right direction. He made regular incisions in the border of the erysipelas extending into the healthy skin, and he crossed these diagonally with others. The object was to give a good chance to the cocci to get to the surface and come in con- tact with the antiseptic fluid which was applied to the skin ; the dressing was constantly moistened with the antiseptic fluid for a few days. The results were excellent.. Riedel and Lauenstein (Deutsch Med. Woch, for Oct. 19th, 1889) proposed to improve Kraske's method by locating the incisions entirely in the healthy tissue, about one to two inches away from the border of the erysipelas. This was to avoid possible infection of the aseptic tissue. This modification has given better results than any other method. The patients were usually put under an anaes- thetic, and the whole operation performed antiseptically. Dr. Siebert has used this method in three cases in children, with the result of limiting the spread of the affection. He does not put the patient under ether, but uses the " vaccination harrow," and so does away with objections parents have to the employment of anaesthetics. 249 Physiological Resistance of the Peritoneum to Infection.— During the past year Rinne {Archiv fur Klin. Chir., 1889) has made some most interesting experiments in surgical path- ology. Practically and clinically it has been demonstrated that the peritoneal cavity, under certain unknown circumstances, has the power of taking care of a vast amount of filth. Rinne has found that large qnantities of septic material and pure cultures of pyogenic bacteria were absorbed although injected daily into the peritoneal cavity of animals, provided the peritoneal surface was uninjured. The injections produced only mild symptoms in.direct proportion to the quantity of septic material used, and in no case was there more than a moderate rise of temperature. The results were very different when there were coincident defects in the peritoneum exposing the sub-peritoneal tissue to infection. Then there invariably appeared progressive suppur- ative peritonitis going out from the infected connective tissue, which usually terminated fatally. The practical import of these experiments can hardly be over-estimated. They explain why the escape of pus into the peritoneal cavity, from the rupture of a pyosalpinx, is not necessarily fatal if the tube is promptly ex- tirpated and the wound and stump properly treated. They point out that the incision is the point of general danger in all abdominal operations, and they indicate that too great care can- not be exercised in bringing accurately together the peritoneal edges of the wound. They explain why the removal of abdom- inal tumors is so much more dangerous after adhesions have taken place, because the resulting denuded spots offer less re- sistance to the invasion of septic bacteria. They explain the success of those operators who disregard the dictation of scien- tific bacteriology, and also the recovery of patients after abdom- inal section by horned animals. They teach us to consider cautiously the evidence presented by statistics of operators and await the demonstration of mo-e exact methods as to the import of their results. They warn us that clinical evidence is inade- quate to overthrow the deductions of experimental physiology and pathology, and that our time is provided with methods of precision which are yet imperfectly improved. The resisting 18a 250 and absorptive power of the peritoneum is beyond that of any other serous cavity (Journal of the American Medical Asso- ciation, Oct. 17th, 1889). Surgery of the Liver.—Mr. Lawson Tait has a very interest- ing paper on the above subject {Edinburgh Medical Journal, October and November, 1889), in which, in his characteristic and forcible way, he gives the history of this branch of surgery, and details his own experience, which consists in seventeen cases of exploratory incision with one death; seventeen cases of hepatotomy with two deaths, and fifty-five cases of cholecyst- otomy with three deaths—a remarkable record. Petit was the first to describe the operation of cholecystotomy as now per- formed, yet his description of the operation was unnoticed for 150 years until Marion Sims put it into actual practice in 1878. The result in this case was fatal. In 1879 Mr. Tait successfully performed the operation on a woman aged 40. The patient is still alive. Of the fifty-five cases performed by him, fifty- two were successful, one old woman died of a suffocative catarrh some weeks after the wound was healed, two others died of cancer of the liver, which was, in all probability, the cause of the distended gall bladder, for no gall stones were found. In not a single instance did a patient die from the operation. All the other patients, with one exception, were in perfect health at the time the article was written. Mr. Tait's method of performing the operation of cholecystotomy is well known. He stitches the distended bladder to the abdominal wound and then incises it, evacuates the fluid, and removes the stones, leaving a drainage tube in the gall bladder. He condemns the practice advocated by Sir Spencer Wells, of opening the gall bladder, removing the calculi, and then closing the wound in the gall-bladder by continuous suture without attach- ing it to the abdominal wall. As far as Mr. Tait knows, the method has been fatal in every instance where it has been tried. Mr. Tait says it is generally supposed that gall stones form in the gall bladder, but this is not true, for the nuclei of gall-stones are found in the streams of bile as they flow through the sub- stance of the liver. In fact he has cut gall-stones out of 251 abscesses in the substance of the liver. Gall-stone is not a dis- ease of the gall-bladder at all. Mr. Tait says that if this be true there is no justification for the removal of the gall-bladder, ex- cept in cases where it is greatly thickened and suppurating, and that these are the very cases where it is an impossible operation. The one argument against cholecystotomy, viz., that biliary fistulae remain occasionally and permanently, is an argument of much greater force against the removal of the gall-bladder, and the so-called operation of cholecystectomy, for such a fistula, after cholecystotomy, must be due to the fact that the operation had been performed at a time when a gall-stone or gall-stones had become impacted in the common duct. In several of such cases Mr. Tait has crushed this obstructing gall-stone, and has thus succeeded in clearing the common duct. In one case (the ex- ception alluded to above) he succeeded in crushing one stone. At the post-mortem held seven years after, both cystic and common ducts were found obstructed from one end to the other, and the result was the patient had a permanent fistula. She lived comfortably four or five years, and finally died of phthisis. In such a case the removal of the gall-bladder would have been the very worst proceeding possible. Mr. Mayo Robson has recently been successful in making a connection between the gall-bladder and adjacent coil of intes- tine, and in this way the trouble of a biliary fistula was avoided. However, most of these cases may be avoided by the operation of cholelithotrity, that is, make a fresh opening in the abdomen and crush the stone outside the walls of the duct by means of padded forceps. Tait divides gall-stones into two varieties, viz , " solitary " gall stones and " numerous" gall stones. The "solitary" is not always quite solitary, but it has rarely more than one companion. The "numerous" gall-stones are practically indefinite in number, are usually uniform and not of large size. Several interesting cases are detailed. In one the abdomen was opened for a sup- posed par-ovarian cyst The cyst was opened and found to be a distended gall-bladder ; the opening was enlarged, the hand in- troduced, and a large gall-stone, which was imparted in the neck 252 of the bladder, removed ; the opening in the gall-bladder was stitched to the abdominal walls, and a drainage tube inserted ; bile began to flow on the morning of the third day. The woman made a perfect recovery. Disappearance of Tumours after Exploratory Incision.—In the second article on the surgery of the liver, Mr. Tait begins by saying that there are certain diseases, in some instances un- known, which seem to yield to surgical treatment applied to them by accident. He says that he has, on more than one occasion, drawn attention to the astonishing disappearance of tumours, often of large size, after a mere exploratory incision. The ab- solute silence with which these statements have been received by the profession has surprised Mr. Tait. They are true enough, and the experience of others in the future will sub- stantiate them. The cases in which he has seen tumours dis- appear in this way are chiefly cases of diseases of the liver, spleen and head of the pancreas. He has seen others where the exact site of the origin of the growths could not be accurately ascertained. Mr. Tait is satisfied, from the number of these cases seen by him, that the disappearance is not a mere co inci- dence ; he is convinced that the mere opening of the peritoneal cavity has a direct influence in setting up the process of absorp- tion of the tumour, and this conviction has increased his con- fidence in the principle of exploration. That some physiological change is at once set up by opening the peritoneal cavity is clearly indicated by the uniform onset of a most distressing thirst, which lasts for days, and is not seen so markedly after any other operation. In operations down to the serous cavity this thirst does not occur, but let the serous cavity be opened but a finger's breadth and the result is marked. A number of remarkable cases of exploratory incision for tumours, &c.,of the abdomen are narrated, in which the tumours disappeared, although apparently of a malignant nature. One very remarkable case was that of a lady aged 54, who was the subject of symptoms strongly pointing to the possibility of gall- stones ; Mr. Tait's own impression, however, was that she was suffering from cancer of the liver. An exploratory incision was 253 made ; the liver was found scattered with large hard nodules, one of which closely imitated the lump which had led to the diagnosis of distended gall bladder. No doubt was expressed at the time of operation that this was a case of cancer of the hver. At all events, the patient was cured and is at the present time perfectly well. Four times Mr. Tait has opened the abdomen for the purpose of removing enlarged spleens, and in every case he has been deterred from proceeding with the operation by reason of the hopelessness of the outlook for the patient. Strange to say, in three of the four cases the tumour has disappeared, and they are now in perfect health. The fourth succumbed to the explor- atory incision. In another case he explored a tumour which appeared to be in the position of the head of the pancreas, in a lady who had become much emaciated, and was supposed to be suffering from cancer. The exploratory incision resulted in the complete dis- appearance of the tumour in five or six weeks, and restoration to former state of health. Abscesses and Hydatids of the Liver.—Mr. Tait thinks modern surgery is to be congratulated upon the distinct advance it has made in the treatment of abscesses of the liver, and hydatid tumours of that organ. Mr. Tait has on seventeen occa- sions deliberately attacked these two diseases by abdominal section, and in fifteen cases he was completely successful. He was the first to remove hydatid tumour by opening the tissue of the liver, and reports his first case operated on in 1879. The patient recovered without a bad symptom. His method is to incise the liver and stitch its edges to the abdominal wound and put in a drainage tube. Mr. Tait is perfectly sure that there are two varieties of hydatid cysts. The more common is the large single cyst, formed of gelatinous layers easily stripped from one another, the fluid is limpid and free; these are the cysts that are sometimes cured by tapping. The other variety is the multiple variety, where the cysts are numerous, and vary in size from a pin's point to that of a cocoanut; they lie packed together in a cavity of the 254 liver, which is not lined by a sac, and in the wall of each of these cysts there are fastened to the base enormous numbers of scolices of another tape worm. In this class of cases the liver ruptures and the hydatids are poured out loose into the cavity of the peritoneum, and then they penetrate the tissues in all directions. When the author first attacked the liver by surgical opera- tion he was in terror of hemorrhage, for he thought that if an incision opened a large sinus, the arrest of hemorrhage would be a matter of considerable difficulty, but he once, while perform- ing ovariotomy, accidentally tore the edge of the liver and free hemorrhage took place, which was immediately checked by the application of a small piece of solid perchloride of iron. In another case where he incised a large sinus in the liver, he passed a thread down one side of it and up the other, and tied the sinus, thus completely and easily arresting the hemorrhage. In his operation upon abscesses of the liver all the cases have recovered, with one exception. He treats these cases of abscess like any other cyst. He sutures the edges of the liver to the abdominal wound and drains ; the stitches always hold well, and he thinks there is no need of procuring adhesion between the peritoneal surface of the abdominal wall and the wall surface of the liver, and that operations may be done at one sitting with as great readiness upon the liver as upon any other organ in the abdomen. Lumbar Cholecystotomy.—In the last volume of The Trans- actions of the American Surgical Association, Dr. Mears, of Philadelphia, reports the case of a woman, aged 29, who was admitted to the hospital for the operation of nephrorraphy, or fixation of the kidney. She had a rounded tumor about the size of the kidney lying a little to the right of the median line at the junction of the hypogastric and umbilical regions. The tumor was freely movable in all directions. A vertical lumbar incision was made, the right kidney exposed, its capsule divided and stitched to the edge of the wound. The tumor was uninfluenced by this procedure. In pressing it towards the loin it was made to bulge in the wound covered by peritoneum ; the peritoneum was 255 divided, when the tumor was found to be a distended gall- bladder. The fundus was incised and a gall-stone was found in the cystic duct. As it was impossible to extract it, it was crushed in situ and the fragments pushed on into the intestines. The patient made a perfect recovery. The case is interesting rather as a warning than as a guide. Surgery of the Gall Bladder.—At the 18th Surgical Con- gress, held in Berlin, June 1st, 1889, Prof. Credo", of Dresden, spoke on this subject. His observations were based on five cases. All had suffered from gall-stones for years. In case 1 no tumour could be felt, but in others the swelling was evident. In cases where there was degeneration of the gall bladder, and there was no chance of restoring the function of the gall bladder, extirpation was demanded. He had removed the gall-bladder successfully in one case. In the discussion which followed, some surgeons who had extirpated the gall-bladder stated that a bile fistula persisted. Langenbuch had extirpated the gall- bladder 24 times. The more experience he had, the more need he felt of collecting further information. Cholecystotomy was an operation that well deserved recognition, although its results were not so favorable as represented. Out of 75 cases of oper- ation there had been two relapses, 11 deaths, and 16 cases of fistula. He himself had only lost two out of 22 cases. In cases in which he found the common duct filled with calculi, he would not operate at all, or with the greatest caution. At a meeting of the Clinical Society of London, held October 25th, 1889, Mr. Mayo Robson, of Leeds, communicated a paper on 15 cases of cholecystotomy which he had performed, eleven were for gall-stones, one for empyema of the gall bladder, two for distended gall-bladder, due in one case to cancer of the head of the pancreas, and the other to cancer of the bile duct. All the patients operated on for gall-stones recovered. The case of cancer of the head of the pancreas died on the eighth day. Mr. Robson spoke of the difficulty of operation in those cases where the gall-bladder was shrunken, and where it could not be at- tached to the abdominal wall. In one case he sutured a piece of omentum, on the one hand to the gall-bladder, and on the 256 other to the parietal peritoneum, thus shutting off the general peritoneal cavity. This method of omental grafting was sugges- ted by the operations of Dr. Senn. Mr. Robson said that, with due care, he thought the opera. tion of cholecystotomy was attended with comparatively little danger, provided there was no malignant disease. Mr. Knowsley Thornton said it was not always easy to dis- tinguish between a distended gall-bladder and a tumor of the kidney, and cases where there were thick adhesions around the gall-bladder, with suppuration, were difficult to diagnose. If the gall-bladder was distinct, the operation was easy. If the stone had passed into the cystic duct, the operation was difficult. It was a good plan in such cases to break up the stone by needling it. In one case he had slit up the common duct, re- moved the stone, then stitched up the duct; the patient recov- ered. He considered artificial connection of the gall-bladder with the intestine a radically wrong procedure, inasmuch as the opening in the bowel wall was likely soon to close. Mr. Thornton agrees with the German surgeons and, notwith- standing the opinion of Mr. Tait, thinks that cholecystectomy is the operation of the future. It causes no more risk to the patient and effectually prevents another stone from blocking up the cystic duct. Mr. Barker mentioned a case where he had operated and had only found a distended gall-bladder with some hardening of the head of the pancreas ; he had closed the wound, and the patient was quickly better and recovered perfectly. ■Sir Joseph Lister's New Antiseptic Dressing.—At a meet- ing of the Medical Society of London, held November 4th, 1889, Sir Joseph Lister delivered an important address on a new anti- septic dressing {Lancet, Nov. 9th and 16th, 1889). The author described his laborious and painstaking search for a new and more reliable surgical dressing. The address is characteristic of the man, and the story it tells is a revelation of scientific acumen, perseverance and minute attention to detail, which are required for such work; it also displays a wide and practical knowledge of chemistry. This subject has engaged the illustrious 257 surgeon during the last five years, the last report he made was about his bi-chloride of mercury, when he showed that it formed a compound with mercury, which was soluble in blood serum, and he brought forward a serum sublimate gauze*. This not proving entirely satisfactory, Sir Joseph sought for new agents, and experimented with the double chloride of ammonium and mer- cury, called sal alembroth. This was a good antiseptic, and less irritating than bi-chloride, but again objections cropped up, for the compound was soluble not only in water, but in serum, so another series of experiments was made with cyanide of mercury. This was found high as to inhibitory, but low in germi- cidal, power ; it was also irritating and very soluble. The double cyanides were next tried. Mr. Martindale suggested one of the insoluble double cyanides of mercury and zinc, and this compound has proved superior to all substances hitherto used. There are several of these double cyanides ; there seems to be some doubt as to the precise compound which exists in the pre- paration of cyanide of mercury and zinc, but it is certain that the mercury in it is an important, though not in quantity a large, factor. The very ingenious method by which, after many trials, the substance was incorporated with starch, with which it forms a kind of combination whereby it can be affixed to gauze so neatly that in the dry state it does not dust off and in the wet state it does not wash away. Sir Joseph looks upon the gauze as a perfect success ; it is antiseptic, porous, permanent and non-irritating. The double cyanide of zinc and mercury was not at first successful, and some early difficulties caused it to be abandoned. Then iodide of mercury was tried, because it was an antiseptic and sparingly soluble in water. It is more soluble in blood serum, but then it is very irritating, and difficult to fix in the gauze ; the latter objection was removed by the starch, then used for the first time. Here, as with the double cyanide, a loose kind of molecular combination seems to take place and the iodide does not dust off, but the experiment was not satisfactory so he went back to the double cyanides. In wounds about the head or hairy parts, the cyanide mois- tened with a weak solution of corrosive sublimate may be rubbed 258 into the hairy parts, when it will convert the hairs into an anti- septic dressing. In conclusion, the author says that there are those who still believe that the use of antiseptic substances in surgical practice is always useless, if not injurious. The germ theory of septic diseases is indeed now happily estab- lished incontrovertibly. All now admit that septic mischief in our wounds depends on the development of micro-organisms in them derived from without. But the gentlemen to whom Sir Joseph refers are disposed to trust everything to the antiseptic powers of human tissues. Sir Joseph was the first to direct attention to the antiseptic properties of living structures ; with- out it surgery in former days would have been absolutely im- possible. Still he knows too well from experience that it cannot always be trusted, and that the use of antiseptic adjuncts is in the highest degree important. He again says, " I have the satisfaction of knowing that there is among you a constantly increasing number who, when they have operated on unbroken skin with a fair field around for the application of their dressings, if they see septic inflammation occurring in the wound with its attendant dangers, know that it is their fault or the fault of the antiseptic dressings at their disposal. To those among you who are impressed with this conviction, I offer the dressing which I have described as the most satisfactory that I have hitherto met with." The Construction of a New Bladder after Excision.—At the Surgical Congress recently held at Bologna, Professor G. Tizzoni, of the University of Bologna, and A. Poggi, gave an account of some experiments they had made on dogs, with a view of ascertaining whether the bladder could be removed and an efficient substitute constructed by operation. First of all laparotomy was performed, and a loop of small intestine about 7 centimetres in length, with its mesentery attached, was iso- lated by two transverse cuts, washed out with a carbolized solution and tied at both ends, one extremity being fixed in front of the neck of the bladder. The two ends of the divided gut were then stitched accurately together by circular sutures. The dog soon recovered from the operation, and a month later 259 the second stage of the operation was performed. The ureters were separated from the bladder and the latter was completely removed. The loop of intestine destined to be the new bladder was then cut across at the lower end and then stitched to the neck of the bladder. The ureters were then turned into the artificial bladder. A slender elastic drainage tube was placed in the urethra to carry off the urine during the first few days. The animal recovered perfectly, and gradually acquired control over its new bladder, and when shown to the congress two months later showed no signs of incontinence. The operation has been repeated with success on several animals, and Drs. Tizzoni and Poggi are hopeful it may be applicable to the human subject.— {London Medical Recorder). Trephining the Sacro-Riac Joint.—Mr. Mayo Collier, (Lancet, Oct. 19, 1889), reports a case of sacroiliac disease successfully treated by trephining. The case was a lady aged 34, who had suffered for some four years from pains in and about the right hip and lameness. She was treated for ovarian irritation by massage, etc. Mr. Collier diagnosed the affection; the patient had a tuberculous family history ; pain was com- plained of on walking or sitting on right tuber ischii, pain on coughing, on deep iliac pressure, and when the ilia were pressed together ; pain was also marked on pressing immediately over the joint behind. Thomas' splint did not relieve the case, so Mr. Collier decided to trephine the joint from outside. A curved incision eight inches long parallel with and an inch below the posterior third of the crest of the ilium and descend- ing vertically over the joint, exposed the bone sufficiently. The bone was next denuded with the elevator, and now was seen to be distinctly swollen and inflamed. A line being drawn from the anterior superior spinous process to the posterior, two inches were measured from this posteriorly. The pin of the trephine was placed on the line so that the edge of the circle should be on the two inch line. The joint was rapidly penetrated. It was found denuded of cartilage and the bone was eroded. The diseased structures were removed with gouge and mallet and the joint swabbed with chloride of zinc (40 grs. to the 260 ounce) ; a large drain was introduced. The patient rapidly recovered and in six months was able to return to her home in South Africa. Healing of Aseptic Bone Cavities.—Dr. N. Senn, {American Journal of the Medical Sciences, September, 1889), has a most interesting article on the healing of bone cavities. Neuber, of Kiel, some years ago introduced a method of implantation of skin flaps, after ehiselling or gouging the bone sufficiently to allow the soft parts to be brought into contact with the floor of the cavity. These flaps were fastened securely into position with bone nails and in many cases primary union resulted. Schede and others also attempted to secure healing under aseptic moist bloodclot, and good results have been obtained, but also there have been many failures. Dr. Senn substitutes for the bloodclot aseptic decalcified bone chips ; they are absorbable, firm, and form a good scaffold upon which granu- lations can be supported. He made a number of experiments on dogs before applying the method to man. The results have been apparently satisfactory. In operations on the skull he fits an aseptic bone-disk into the trephine opening ; this arrests hemorrhage from the bone and prevents adhesions between the dura mater and external parts, it is gradually absorbed, a mass of granulations takes it place, and the defect is closed by dense cicatricial tissue or by bone. The disk is perforated for the purpose of drainage and to allow the granulations to pene- trate easily. For the healing of bone cavities, chips of decalci- fied bone are used, after thorough disinfection of the cavity and dusting the bone chips and cavity with iodoform, the decalcified bone is rendered thoroughly aseptic and antiseptic by keeping it immersed in sublimate alchohol (1-500). . The wound is com- pletely closed with the exception of the lower angle where a capillary drain of a few threads of catgut is introduced. Rapid healing takes place in one or two dressings, with entire restoration of the continuity of the bone. His conclusions are— (1). Antiseptic decalcified bone is the best substitute for living bone grafts in the restoration of a loss of substance in bone. 261 (2). Implantation of a bone disk into a trephine hole may be relied on as a hemostatic measure in arresting hemorrhage from the vessels of the diploe, and is a good temporary substi- tute for the lost portion of cranium. (3). The packing of an aseptic bone cavity with antiseptic bone chips guards against unnecessary loss of blood and prevents infection by pus microbes. (4). Capilliary drainage should be established after implan- tation to remove the accumulation of more blood in the wound than is necessary to form a temporary cement between the bone chips and surrounding tissues. (5). Packing by bone chips acts as an antiseptic tampon. 6). Secondary implantation can be successfully carried out in treating a suppurating bone cavity after suppuration has ceased, and the cavity can be transformed into the same favour- able conditions for healing as an aseptic wound. '■*> ^ NLM005549612