cedure is based, I do not know. Do you think that you can drain the bacteria out of the tissues? You can certainly not. When the pus has been formed it is the proper procedure to open and drain after the old Hippocratic rule: "Ubi pus, ibi evacua," but when there is only inflammation produced by bacteria in the tissues of the broad ligament, etc., there is absolutely no use for such a thing and I am glad that this subject was not mentioned at all by previous speakers. The drainage must be performed through the lowest possible part to make it as effective as possible, and that for this purpose in women the vagina is the natural route, is nowadays generally recognized. Unfortunately many lives have been lost by the advo cates of the abdominal route for these case before they were converted and convinced of the fallacy of their principles. In cases where there are many abscesses in the broad ligament and in cases, in which, when one abscess is broken up and drained, others are formed higher up, only most radical measures can oftentimes save the life and in these cases I extirpate the uterus with the tubes and ovaries by the vaginal route, thereby broadly opening the broad ligaments and instituting free and thorough drainage. Another question is: shall one in case of gonorrheic infections of both tubes, when both tubes are palpable and almost swollen to the extent of a little finger, advocate operative treatment or conservative procedures? This if oftentimes difficult to decide and there is no law for every case. I observed a woman who showed the above conditions and whom I treated conservatively for about four years. The other day I received a letter announcing the birth of a healthy boy. It is well known that these cases can heal out by conservative treatment if the women have only the patience to follow the instructions. Not so seldom extra-uterine pregnancy develops in such cases afterwards.

Dr. Puls: I have very little to add to what has been said. Very little has been said regarding the etiology that I need go

over. The last speaker mentions something about operating for acute cases. Of course he means by that, that abdominal operations have been advised. I do not think that has been done more frequently in this country than anywhere else. I know that Dr. Henrotin is one of the advisers of vaginal operations in acute cases, but he selects his cases. He makes an opening into the vagina and drains to prevent pus formation. We do not know when the pus will form in an acute case, but as a rule it takes eight or ten days for the onset, but this operation is intended to secure good drainage. He opens up the Douglas by an elliptical incision, loosens the adhesions which have been formed and drains to avoid a general ascending infection.

When pus is found free in the pelvis as Dr. Shimonek has said, thorough drainage is certainly necessary, and the best way to get at it is through the vagina. I remember a case I saved through abdominal drainage; it was a case of acute peritonitis in a girl of 18, who was apparently dying, by simply opening up the abdomen anteriorly at different places and irrigating with salt-solution, she recovered. That case was obscure; I do not know where the pus came from; it was impossible for me to get at the vagina or into the cul de sac, as everything was matted together. It was remarkable that I got there just in time to prevent death. I think the salt-solution had something to do with removing the shock.

CHOLELITHIASIS: DIAGNOSIS AND SURGICAL TREAT

MENT.

BY WM. MACKIE, M. D., OF MILWAUKEE.

The diagnosis of gall-stones must, as a rule, be by exclusion. A positive diagnosis can be made when a stone is found in the feces, or a tumor imparting a grating sensation can be palpated at the border of the costal arch over the site of the gallbladder; a contracted bladder filled with stones.

Accepting an infection, either directly from the intestine or through the circulation, as the explanation of their origin, the occurrence of the infective processes, cholangitis and cholecystitis as an accompaniment is evident. It further suggests the importance of entering very fully into the previous history to ascertain a possible prior source of infection, as an intestinal catarrh, typhoid fever, or an ulcerative process of the intestine. Of thirty-one cases operated upon, Cushing found in ten, or one-third, a history of typhoid fever.

Cholelithiasis occurs about, or after, the middle period of life in those of sedentary habits, and is preceded by some gastrointestinal disturbance. Of symptoms, pain, the earliest and commonest is not invariably present. There may be a premonitory sense of discomfort or uneasiness in the region of the liver, or the onset may be sudden-the characteristic biliary colic, the result of the passage, or the attempted passage, of the stone through the ducts. It is paroxysmal, in contradistinction to inflammatory. Movement does not aggravate, as shown by the restlessness, nor does pressure. The latter may be grateful. The reverse holds true in all inflammatory affections. It starts in the region of the bladder, radiates around the right side, and extends upward behind the right shoulder-blade and interscapular space.

The pain under the scapula is taken to indicate obstruction of the cystic duct. Billings induced the localization of this pain by post-operative catheterization of the duct. The localization of the pain one inch to the right and the same distance above the level of the umbilicus points to common-duct obstruction. This, combined with subsequent tenderness to deep pressure, Mayo Robson considers diagnostic of common-duct trouble. A tender point to deep pressure opposite the cartilage of the ninth or tenth ribs favors cystic-duct obstruction. Chills and fever accompany or follow the paroxysmal pain. The fever is irregular as to time and character. Its short duration is remarked. Those tender points to pressure, and fever, are the manifestations of cholangitis and cholecystitis. When the cholecystitis becomes chronic, there follows hypertrophy of the wall and subsequent contraction, giving the contracted gallbladder filled with stones. In such cases the cystic duct must remain patent and without stricture-formation to prevent the free escape of the secretions. If the inflammatory process

extend beyond the confines of bladder or duct-wall, then there arises a localized peritonitis with adhesion-formation. Under these circumstances the points of tenderness referred to would be greatly aggravated. Jaundice supervenes in twenty-four to thirty hours in less than half of all cases. It is of more frequent occurrence in obstruction of the common duct. The degree will be proportionate to the duration of complete obstruction. Continuous and complete obstruction of the duct is the exception. Were the reverse the case, distention of the gallbladder must necessarily follow, and become evident by the presence of a tumor in that region. This is still taught in some of the more recent text-books (American Text-Book of Surgery, Park's Surgery, and Dennis' Surgery, 1896). In 1890, Courvoisier, from an analysis of 187 cases, showed that distention of the gall-bladder was rare. In reviewing, Cabot

formulates the following law: "When the common duct is obstructed by a stone, dilatation of the gall-bladder is rare; when the common duct is obstructed by other causes, dilatation of the gall-bladder is common." Two years later, Mayo Robson, independently, came to a similar conclusion, stating that jaundice with distended gall-bladder is presumptive of malignant disease, but jaundice without distended gall-bladder, favors the diagnosis of cholelithiasis. Cabot, from a critical review of his own cases, confirms this view. A study of many recorded cases submitted to operation likewise verifies it. The explanation given is that the obstruction is incomplete, an intermittent flow of bile into the duodenum takes place, either from the ballvalve action of the stone, as described by Fenger, or the irreg ular contraction of the gall-bladder and ducts. The conclusion must now be accepted that jaundice of an intermittent character, or of varying intensity, is diagnostic in uncomplicated cases of obstruction of the common duct by stone. There may occur some exceptional cases as where a large stone in the ampulla of Vater compresses the duct in its passage through the wall of the duodenum. In obstruction of the cystic duct there is no jaundice unless a cholangitis be also present to obstruct the opening of the common duct. In this case, likewise, there is no distention unless a cholecystitis supervenes with closure of the duct from a swelling of the mucous membrane, or the irritation of the stone give rise to a stricture. In either of the latter conditions the gall-bladder may become enormously distended and project as a palpable tumor directly downward. To the existing cholangitis and cholecystitis the attacks of biliary colic have been assigned by Kehr, and not to the impaction of the stone. When a pyogenic infection occurs in a simple calculous cholecystitis with obstruction of the duct, an empyema of the gall-bladder is the result, accompanied by the general systemic symptoms of pus.