at the proper time, place itself in relation with the State Medical Society, by electing delegates thereto.

I would also suggest that the members of this society, as individuals, undertake to work up public sentiment on the question of laws and the enforcement of them, against charletanism and quackery, and in favor of the encouragement of educated and competent physicians.

hope that the disease would not return. I cannot imagine any other kind of disease of the gall-bladder which would be incurable; for in some of my cases suppuration has lead to almost complete disorganization of the organ, and yet, after drainage for some weeks, it was completely restored to its functions, whatever they may be. Dr. Bernays says that ideal cholecystotomy is indicated when the bladder is normal in structure, and when the gall-ducts have been cleared of obstructing calculi. But he seems to be perfectly

BY AUGUSTUS C. BERNAYS, A. M., M. D. HD LBG. M. R. C. S., ENGLAND.

Professor of Anatomy, St. Louis College of Physicians and Surgeons.

In the Lancet published in London Eng., on February 13, 1886, Mr. Lawson Tait gives to the profession a history of five cases of cholecystotomy, they being the five latest of his series of twenty-one successful cases. At the conclusion of his article is found the following criticism of my paper on the same subject:

"By far the best of the recent papers on cholecystotomy is one by Augustus C. Bernays of St. Louis, which appeared in the WEEKLY MEDICAL REVIEW for Oct. 31. The title is one which is a little puzzling until the paper is read "Ideal Cholecystotomy"; and the author discusses three possible operations for the surgical treatment of gall-stones. His "ideal cholecystotomy" is that where he can close the opening into the gall-bladder and drop the cyst back; and for the first time in his hands this operation has been successful. The second operation of which he speaks is what he calls "natural cholecystotomy"-that is to say, the operation I have performed successfully twenty-one times, imitating the process of nature by securing the adhesions of the gall-bladder to the abdominal wall, and the formation of a fistula as part of the treatment. The third operation is "cholecystectomy" which he says, should be limited to cases of otherwise incurable or malignant diseases of the gall-bladder.

One or two points in the paper are worth a little discussion. The last which I have mentioned the limitation of cholecystectomy-I should extend further than Dr. Bernays has done; because nothing would induce me to rea cancerous tumor of the gall-bladder, for there could be no reasonable amount of

move

which I have completely established, that it is absolutely impossible to be sure that the gall-ducts have been so cleared. His own case of successful ideal cholecystotomy was an example of which I have seen a considerable number, where, by the chronic inflammatory change effected by long impaction of gall-stones, the duct was practically obliterated. In such cases the regurgitation of bile after the operation does not take place until the inflammatory effusion has subsided, many days after the operation, sometimes two or three weeks; therefore it was not really a fair chance to test the efficacy of his ideal opera tion; and supposing that the accident of subsequent suppuration took place, a not unlikely thing after such an operation, nothing could happen but that the suppurating gallbladder would discharge its contents through the aperture made at the time of the operation. One other point is the consideration of the possibility of a subsequent formation of gall-stones, and is a very strong argument, in my own mind, against Dr. Bernays' ideal cholecystotomy; for if such a thing should happen, the whole operative process must be gone over again. On the other hand, if my proposal, characterized by Dr. Bernays, and very appropriately, as natural cholecystotomy, had been carried out, a single incision into the adherent gall-bladder, guided by a tattoo mark, which can be very easily left to iden tify the site, would enable complete and effectual relief to be given without any risk at all. This is an argument in favor of the operation I advocate, which I have frequently pointed out, and which I desire again to put into prominence. In all other respects I entirely agree with Dr. Bernays, more particularly in his condemnation of the transcendental cholecystotomy of Dr. Gaston."

Mr. Tait's first objection is directed against my conclusion which reads as follows:

IX. Cholecystectomy should be limited to cases of otherwise incurable or malignant disease of the gall-bladder.

His objection involves the question of the

curability of malignant tumors by surgical interference. He says "there could be no reasonable amount of hope that the disease would not return.' "" I take a more hopeful view of these cases, and think that, considering the rather isolated position of the gallbladder, an early removal of an epitheliomatous, or even of a sarcomatous, gall bladder might be successfully done, and might not be folowed by a recurrence. (The entire gallbladder has been removed successfully eight times during the last five years in Europe, in cases where gallstones were the only cause.) But granting that the removal should be followed by a return, would not the operation still be permissible, as a palliative measure, intended to prolong life and lessen pain? Mr. Tait and I are perfectly agreed that the operation of cholecystectomy, as performed on the continent by Langenbuch and others, for the cure of gallstones, is bad practice. Mr. Tait would have the operation discarded entirely. I would limit its performance as above stated. Mr. Tait says that he can not imagine any other kind of disease of the gallbladder which could not be cured by the establishment of a fistula and drainage. I would refer Mr. Tait to a condition of affairs described by Dr. W. W. Keen, of Philadelphia, where there was a formation of a dense mass of cicatricial tissue binding down and obliterating the cystic duct, and forming strong bands of adhesions between the gallbladder and the adjacent organs. It does not require very much imagination to see that cholecystectomy might be a useful procedure in similar cases, where the gallbladder has degenerated into a mass of cicatricial tissue, and is no longer a vehicle for the bile, but only the cause of serious pain and other more dangerous symptoms.

The second objection of Mr. Tait is directed against the ideal cholecystotomy. His ar gument hinges on the possibility of ascertaining whether or not the gall ducts are cleared of obstructing calculi. He denies this possibility. I have shown in my former paper that the incision in the linea alba is preferable to the one along the free margin of the ribs, when there is doubt about the seat of the obstructing calculus. Now, it seems to me undeniable that from an incision in the linea alba, between the ensiform process and the umbilicus, all the bile ducts commencing at the gall bladder and down to the duodenum, are made easily accessible to the search gnd. The same can not be said of the incision parallel to the rib, as practiced by Mr. Tait. I, therefore, maintain some cases absolute certainty can

that in

be gained that the entire system of ducts is cleared of obstructions, and for these cases my ideal cholecystotomy will be the proper operation, when the tissues of the gall bladder are found normal. In speaking of my successful case, he assumed that there was no regurgitation of bile after I had removed the obstructing calculus, by supposing that the cystic duct had become practically obliterated by a chronic inflammation below the seat of the stone. He thinks that no bile could enter a gall bladder under these circumstances, and, consequently, there could be no pressure within the recently sutured sac until the cut had entirely healed up.

After I had finished my operation of ideal cholecystotomy, I certainly expected that bile would pour into the gall bladder in a very short time, if not while I was still engaged in the process of closing the wound. The cystic duct was certainly open as were all others in my case. I made sure of this point by passing my hand from the gall bladder to the duodenum. Furthermore, I do not think that any chronic inflammation will be found below the seat of obstruction, i. e., towards the duodenum, either in the mucous, muscular, or peritoneal coats of any of the gall ducts. My reason for this is that the blood current supplying these ducts runs in an opposite direction from the bile, consequently there can be no venous stasis which might give rise to a hyperemia and chronic inflammation below the obstruction, as we sometimes see in the urethra, when a calculus becomes impacted. Chronic inflammation and thickening will be found above the seat of the obstruction only. Finally, when we consider that the pressure in the system of gall ducts, in a normal condition, is very low indeed, the danger of rupturing the fresh sutures seems to me to be exaggerated by Mr. Tait. The possibility of suppuration setting in was duly considered by me, and I have, heretofore, restricted the indication for my ideal cholecystotomy to such cases, in which the bladder is normal in structure, and where suppuration is not at all likely to take place.

The possibility of the recurrence of gallstones finally is said to be a strong argument against my operation. Now, if indeed, there should be a subsequent formation of gallstones, which we must concede to be a remote possibility, it seems to me that a patient operated on by the ideal method would not be a whit worse off than one operated on by Mr. Tait's natural method. In both cases the gall bladdor might have to be reopened, and it is a question, whether the operation would not be more difficult in those cases where a

fistula had once existed, than in those where the bladder had been dropped back. My patient up to the present day has had no trouble of any kind, indicating a return of gall stones, and I have not heard that Mr. Tait had to reopen a once closed gall bladder after removing all the obstructions present. Finally, let me say that I perfectly agree with Mr. Tait in all other points, and I hope that this short discussion will lead to a mutual agreement on all points. It is clear that Mr. Tait's natural cholecystotomy will be performed in a very large majority of cases, but the ideal operation undoubtedly deserves a place among recognized procedures under the limited indications which I have given it. 903 Olive Street.

PSOAS ABSCESS.-DRAINAGE FROM LUMBAR REGION AND GROIN.

REPORTED BY ALEXANDER F. LEE, M. D., Demonstrator of Anatomy and Adjunct to Chair of Surgery.

Case from the Clinic of Dr. Wm. A. Byrd, Prof. Clinical Surgery, Quincy College

of Medicine.

John S., aet. 27, admitted to hospital January 1, suffering with severe pain in the left lumbar region. Had first noticed it about two months previous to his admittance, the pain having steadily increased in its intensity. He had considerable fever with nightly sweats. Appetite very poor; tongue consid erably coated and furred; bowels somewhat constipated; urine high colored but otherwise. normal. Pressure over region of left kidney excited great pain.

A diagnosis of perinephritic abscess was made, and an exploratory aspiration made into the painful part. No pus was obtained, but believing this to be on account of the small calibre of the needle, and the thickness of the pus, it was determined to evacuate it through a deep incision, and at the same time secure thorough drainage.

re

December 28. The patient was anesthetized, an extensive incision made, and a large quantity of pus evacuated. For some time after the operation, marked improvement was ob served. But the fever and night sweats curred and the patient complained of intense pain and tenderness in the left groin. It was now evident that there was a psoas abscess with insufficient drainage, and that if permitted, it would eventually point below Pouart's ligament.

January 15th he was again anesthetized, and a large sized probe passed through the opening in the lumbar region, downwards along the sheath of the psoas muscle, until the point could be felt in the groin. An incision was then made down upon the probe, which was pushed on through the opening. A drainage tube was now secured to the probe by a string and the probe withdrawn through the original opening in the lumbar region, drawing the tube after it. The tube was secured in position by attaching a string to its two ends over the left side, and the patient returned to his ward. Free and thorough drainage was now obtained. The sinus was washed out daily. Suppuration, however, continued unabated, and death from exhaustion resulted January 28.

Post-mortem examination showed the cause of the psoas abscess to be caries of the first and second lumbar vertebrae. A long sinus, containing sphacelated tissue, was found behind the sinus containing the drainage tube, the two communicating below Poupart's lig ament. Right kidney enlarged, and somewhat fatty and ulcerated at posterior part of pelvis. Liver greatly enlarged-about twice its natural size. Other organs normal.

NOTE. In both hospital and private prac tice peroxide of hydrogen is used in the dressing of wounds. It acts admirably, being an excellent antiseptie, dissolving pus and thoroughly cleansing pus cavities. Small cavities and interstices are cleansed by this means that otherwise cannot be reached.

CORRESPONDENCE.

A CORRECTION.

New York, July 21, 1886. Editors Review: Will you kindly have corrected the correspondent's mistake as to my name in your journal (issued June 20), under heading of New York Pathological Society Proceedings of June 4th, in which he gave my name as Dr. Lane, presenting an ovarian cyst (probably dermoid), weight 69 pounds.

It should be Dr. Liell, and by correcting same, you will kindly oblige,

Yours, very sincerely, EDWARD N. LIELL, M. D. 268 W. Thirty-Eighth Street.

--The sad news has just reached us of the death of Dr. W. L. Barret's only son. The doctor had recently gone to Ashville, S. C., with his family, for their summer vacation, and it was

there that little Arthur died.

WEEKLY MEDICAL REVIEW,

EDITED BY

THE MEDICAL PRESS AND LIBRARY ASSOCIATION

914 LOCUST STREET, ST. Louis, Mo.

Contributions for publication should be sent to Dr. I. N. Love, Secretary Executive Committee, Cor. Grand and Lindell Aves.

SATURDAY, AUGUST 14, 1886.

A POSTAL CARD FROM WM. WOOD & Co.

The following postal card will be easily understood:

ED. REVIEW:

NEW YORK, July 13, 1886.

Dear Sir:-The number of Journals to which we forward our publications is now so large that the expense of their delivery has become a serious consideration.

The value of the books thus sent so greatly exceeds the forwarding charges, that we doubt not all editors will willingly pay them; we have therefore decided to hereafter deliver all Editorial copies of our publications to the Express Companies here.

If, for any reason, you prefer not to pay such charges. kindly notify us at once that we may save you the trouble of writing, or of having to return packages we may send you.

WM. WOOD & Co., 56 and 58 Lafayette Place. The answer of the REVIEW at once was, that the editors would be happy to give a fair and prompt notice of the publications, provided a full line were sent expressage paid. Since forwarding our answer we have been informed that a number of journals have taken the same position.

We do not want to be unjust to Wm.Wood & Co., but if we accept their proposition we must do likewise for other publishers; and besides, it is not a high compliment to medical journals to expect them to give space for notices of books, time for reviewing them, and pay expressage for even the most valuable books, to say nothing of others.

We would not object to donating a certain amount of money to a proper cause but not one cent to this.

Another thing that we have no hesitation in speaking of,- some of our publishing houses will send a medical journal their books, thus securing a notice of the house, but neglect to send for review the more valuable

ones.

The REVIEW has a selected staff of reviewers-its space is valuable-and we are willing and glad to give honest notice for honest work. We do not propose to make any discrimination, however, and if a publishing house expects the attention of the REVIEW it must send us its best books as well as its cheapest, properly delivered.

A publishing house has, or should have, as much money to conduct its business, as medical editors have for conducting its affairs for it-and as "the expense of the delivery of publications has become a serious matter," one might conclude that either the house feels unable to pay the forwarding charges, or that it has a poor estimate of medical journals.

We trust neither of these conclusions is correct.

RESTRICTIONS OF MEDICAL COLLEGES.

The justification, if such is needed, for the recent action of the State Board of Health in passing a resolution to require explanations of faculties of schools that turn out a large number of graduates, to a relatively small number of matriculates, is found in the fact of the scandalously high percentages of this kind, quite too common now, in certain schools north and east, as well as west and south.

That these percentages range perilously high, so far as thoroughness of medical instruction is concerned, is certainly true; and this, too, in times when there is a general demand from all quarters that those entering the profession shall be of the best quality in regard to professional training, equipment and accomplishment. This statement is borne out by a glance at the records of schools admittedly the most thorough in their courses of educational study in this country.

The percentages of this character, noted