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brown, dry tongue, showed little improvement until the morning of the fourth day. On this day the pulse was 102° F., the temperature ninety-nine, the tongue moist, and the general condition good, the gall-bladder drain draining freely. From this time on, the convalescence was uneventful. The gauze drainage was gradually removed from the lower wound, which closed up nicely.

The tube was removed from the gallbladder at the end of one week. A few days later, bile began to pass in the stools for the first time. We now strapped over the drainage opening with zinc oxide plaster, which effectually prevented any further leakage of bile.

The patient remained in the hospital four weeks, and then went home in very good condition. She made a complete recovery from the operation, and I presented her to the Academy of Medicine several months later, she being at that time in good health, except for a chronic mucous colitis.

Case 2.-Empyema of the gall-bladder, stricture of the cystic duct, septic intoxication, adhesions of duodenum, pylorus and omentum to gall-bladder, and inferior surface of the liver, large calculus in the gall-bladder, chronic dyspepsia.

Mrs. K., aged sixty-four. She has suffered from indigestion for the past twenty-five years. During this time, in addition to discomfort after eating, and inability to eat many of the ordinary articles of diet, she has suffered numerous attacks of acute indigestion, accompanied by pain in the epigastrium and vomiting. Dr. Dunham, of this city, has seen her in several. She would be confined to the house for several days. She always located the pain in the epigastrium. She has never been jaundiced.

On September 15, 1904, she again became sick. Dr. Dunham saw her this time, and prescribed for her. She was confined to her bed for several days, and had fever up to 101° F. She was weaker, and was confined to bed longer than usual. On October 1st she noticed a tumor in the right side below the costal border. Dr. Dunham saw her a day or two later, and confirmed the presence of a mass at the location of the gall-bladder, which was quite sensitive. I saw her with Dr.

Dunham, on October 7th. By this time the mass extended from one inch below the costal margin downward, and inward to a point one inch below the level of the umbilicus, and one inch to the right of the median line. It was tender, elastic, and could be moved from side to side, and pushed upward. It was very evidently a distended gall-bladder.

Her temperature at this time was 101° F., therefore, in addition to a distended gall-bladder, we, in all probability, had to deal with an empyema of the gall-bladder. On palpation of the stomach from left to right gurgling of gas occurred, showing that there were adhesions to the pylorus, with partial obstruction. It was thought that in all probability we had to deal with a stone impacted in the pelvis of the gallbladder, causing retention of the secretions of the gall-bladder, notwithstanding she had never had any definite symptoms of gall-stones, such as colic or jaundice. We could exclude malignant obstruction, due to a growth in the pancreas by the absence of tumor, and by the history which showed clearly an acute process. There was, in addition, no appearance of cachexia.

Operation was advised, to which the patient at first declined to submit, but finding herself getting no better, she entered Agnew Hospital, on October 14th, and was prepared for operation, which was done next day.

This preparation of a patient for an abdominal operation is simplicity itself. The patient takes a hot bath, and receives two ounces of castor oil at three o'clock in the afternoon, before the operation. This effectually clears the alimentary canal, and does not abstract a large volume of water from the system, as does a saline cathartic. A point of the greatest value in abdominal work is that after castor oil purging the intestines are, as a rule, as flat as ribbons, therefore, they can be packed away from the field of operation very readily, without using undue force.

Operation.-An incison was made, one inch to the right of the median line, through the rectus muscle, and the abdomen opened. The gall-bladder presented in the incision. The pylorus and duodenum were adherent to the neck and left

side of the gall bladder, and under surface of the liver, just internal to the neck of the gall-bladder. The omentum was adherent to the fundus. These adhesions were old, and evidently had existed for many years. They were dissected away. The gall-bladder was walled off by gauze packs, and the fundus brought out of the wound and tapped, removing six ounces of pus and mucus. The opening was enlarged and the stone removed from the neck of the gall-bladder, which was now wiped out with dry gauze. After packing the gall-bladder with gauze, the common and hepatic ducts were gone over carefully, and found free from stones. The pancreas was not enlarged, nor was it indurated.

The pyloric end of the stomach and duodenum showed no evidence of ulcer, either old or recent. On removing the packing, no bile entered the gall-bladder, so that its removal became necessary, since we know that in case of drainage of the gallbladder where there is a stricture of the cystic duct, a permanent fistula will result, since the walls of the gall-bladder secrete about one ounce of mucus daily. This was done by Mayo's method-ligation of the artery and duct, and removal of the gall-bladder from below, upward. In this case I dissected off enough peritoneum from the gall-bladder to cover in the bed of the gall-bladder after removing it.

I tied the cystic artery where it crossed the cystic duct. I next ligated the cystic duct separately.

After removing the gall-bladder, I placed a purse-string suture around the cystic duct, and tied it, thus covering in its stump. The peritoneum was brought together by a continuous cat-gut suture. The abdomen was now sponged out, and as there was no oozing, and as I felt that the duct and cystic artery were securely closed, I closed up the wound without drainage, using cat-gut sutures for the different layers. The skin was closed by the sub-cuticular method.

The highest temperature after the operation was 100 2-5° F., which occurred on the third day. She suffered no shock, and had very little pain after the operation. I had the greatest difficulty in convincing her that she could probably digest

almost any kind of food, for she had suffered so long that she had no confidence in her stomach. However, on testing different articles of diet, she found that she could digest anything she cared to eat, much to her surprise, as she had not comprehended the fact that the operation was intended to relieve her stomach symptoms.

Dr. Dunham reports that she is now able to digest anything and everything she eats, without discomfort.

These two cases show that gall-stones may exist for many years unsuspected, until one of the complications arise. In both these cases we find that they had suffered for many years with so-called indigestion, in all probability due to the adhesions which were found at the operation. Doubtless had these patients been subjected to a careful examination during the attacks of so-called acute indigestion, keeping the possibility of gall-stones in mind, it would have been noted that the upper portion of the rectus muscle was rigid, and that pressure over the gallbladder would have increased the pain in the epigastrium.

Murphy's test is of great practical importance in the diagnosis of stones in the gall-bladder. It consists of pressing the fingers deeply under the ribs at the ninth costal cartilage, and requiring the patient to breathe deeply. When the gall-bladder descends until it strikes the fingers, a sharp pain is felt, and inspiration is suddenly arrested.

In cases of chronic indigestion, unrelieved by appropriate remedies, the possibility of gall-stones should always be kept in mind, and a physical examination should be made. It is astonishing how easy it is to make a diagnosis in some cases, once our attention is drawn to the possibility of gall-stones, even in cases that have not had colics or jaundice.

In Case 1, we have a history of gallstone colic twenty-five years previously. I have no doubt, from the appearance of the stones, that they had been in the gallbladder since that time, remaining dormant, and only their results, the adhesions, causing trouble with the emptying of the stomach.

At that time the diagnosis had been correctly made, but the patient had for

gotten it when she became ill, and only remembered when told of the results of the operation.

I do not care to dwell on the diagnosis of the typical cases, characterized by colics, scapular pain, jaundice, etc., but I do wish to draw attention to the possibilities of gall-stones, the cases cited showing that a patient may have gall-stones for years, and, finally, when old and weak, and after suffering for many years, they come to operation that is imperative, in order to save their lives. I might add here that these cases demonstrate conclusively that the operation, in good hands, even in bad cases, is not a dangerous one.

It has been shown by Mayo Robson that in cases where stones were left in the common duct at the time of operation, on account of the bad condition of the patient, injections into the fistula were inefficient. How foolish it is to expect results from medicines taken into the stomach. On the other hand, operations for removal of the stones from the gall-bladder have a mortality of less than three per cent, which includes cases of empyema. Choledochotomy, in addition, gives a mortality of about six per cent.

Mayo Robson, in his late work, gives twenty-seven complications that may result from gall-stones, the most important of which are: Empyema of the gall-bladder, as in the two cases reported; localized peritonitis with adhesions to the stomach; perforation of gall-bladder; general septic cholangitis; cancer of the liver, of which I have seen two cases this year; subphrenic abscess; chronic pancreatitis; chronic invalidism and inability to perform the ordinary duties of life, with which we are all famaliar.

How many persons, in all walks of life, fail utterly from this cause? For they are liable to be laid up just when they have important business on hand, and being unable to attend to it, someone else is called in. If the person is employed, no matter how good a man he is, someone else gets his place. If a professional man, someone else gets his professional work. If a business man, he fails because he can not give to his business the attention it deserves.

Cholecystotomy, removal of the stones and drainage, with three weeks' loss of time would cure these cases, for it has been shown that gall-stones do not recur in the gall-bladder after removal.

Coming back to the cases of empyema, it will be noted that in Case 1 I drained the gall-bladder, while in Case 2 I removed it. In case of impacted stone in the neck of the gall-bladder, or cystic duct, I do not recommend or practice removal of the gall-bladder if bile enters it after removal of the obstruction, unless its walls are very badly damaged by inflammation, for with drainage of the gallbladder it will recover practically completely. In Case 2 I had to deal with a closure of the cystic duct. In such a case it becomes necessary to remove the gall-bladder, since if this is not done we would have a permanent mucous fistula, which will discharge from one and onehalf to two ounces of mucus daily.

In conclusion, I would say that gallstones are essentially foreign bodies that give rise to much suffering, and not a few deaths; that we are unable to say when a simple case of stone in the gall-bladder might not become lodged in the common duct, producing a condition that, if unrelieved, will lead to the death of the patient.

That many cases lead to chronic disability from interference with the stomach and duodenum, by adhesions set up as a result of local peritonitis; and that operations for stones in the gall-bladder are never followed by recurrence in the gallbladder. Therefore, we should operate as soon as the diagnosis is made, for operations for stones are much safer, and fewer operations will have to be done on the common duct if the operations are done early, which would mean that most of the operations would have a mortality of less than three per cent, and this will ultimately be reduced, I think. 413 Rialto Building.

I have occasionally in the past read a copy of the MEDICAL BRIEF, but recently came across a copy which I found so helpful and timely that I enclose herein one dollar for a closer intimacy with your journal for 1905.-L. B. BATES, M. D., St. i Matthews, S. C.

[Written for the MEDICAL BRIEF.] Venereal Sores Clinically Considered.

BY EUGENE FULLER, M. D., Professor of Venereal and Genito-Urinary Surgery in the Post-Graduate Medical School and Hospital; Visiting Genito-Urinary Surgeon to the City Hospital, etc.; Author of "Diseases of the Genito-Urinary System." New York City.

When a patient appears with a sore on the external genitals, the consultant should never jump at the conclusion that the lesion must necessarily be of a venereal nature, or if it is such that its presence bears any direct relation to a preceding sexual attack. In other words, a given lesion may be classed under one of three headings:

1. It may be the direct result of infection following sexual intercourse, in which case it is chancre or chancroid.

2. It may have occurred entirely independently of such preceding cause, or if so dependent, it may not be of an infectious nature.

3. And lastly, it may be a late syphilitic lesion, the presence of which bears no relation to any recently preceding coitus.

The first question which is usually and very properly asked of a patient with the above complaint relates to the existence of preceding sexual intercourse. If such has existed, it is of importance to ascertain just how many days have elapsed between the exposure and the discovery of the sore. If the period named be two to four days, or thereabouts, chancroid should be thought of. If it be ten or twenty days, or even longer, up to thirty, and perhaps forty days, the evidence would point toward chancre. The examiner should, however, be very careful not to be misled by the answers of the patients to his first direct questions. If a short interval be given to represent the time between the exposure and the sore, the sexual history of the individual shortly previous to the last coitus should be investigated.

As a result, it may be found that in that time coitus on numerous occasions had been practiced with the same or with various individuals. If such be the case there is, of course, no reason for supposing that the true period of incubation of the sore is as brief as was at first sus

pected. There seems often to be displayed an inclination on the part of patients to lay the blame for any trouble they may discover on the last person to whom they were exposed. The wrongful denial of the existence of preceding sexual exposure is rare as regards men, but somewhat frequent as concerns women. The examiner should also be careful not to be carried away with the supposition that a venereal sore exists because a patient possessed with that idea is very definite in stating the period of incubation. Many individuals after suspicious coitus become worried, and as the result of repeated examinations of their genitals, think they discover a resulting lesion, either in some congenital or long-existing blemish, or in some slight development which would otherwise have escaped notice. Where the complaint is that a genital lesion was noticed almost immediately or the next day after exposure, it is quite probable that the act itself was productive of traumatism sufficient to account for the manifestation in question.

The purpose of a second set of questions is to ascertain, if possible, the amount of pain and discomfort occasioned by the lesion. If the pain is extreme, keeping the patient awake at night, and being much aggravated as the result of bodily disturbance, the indication would point toward chancroid, while, on the other hand, if the sore be remarkably free from such characteristics, chancre would be indicated.

Although these subjective features are of value, still one should always bear in mind that chancroid may be so tolerated by a phlegmatic individual as to occasion little discomfort, and no real pain; and, on the contrary that chancre generally on the person of a sensitive or neurotic individual may be described as vividly painful. The only other question worth asking before a visual examination, relates to whether the lesion in question be single or multiple. The usual singularity of chancre and the frequent multiplicity of chancroid are points of importance.

Although the period of incubation of chancroid is usually stated to be from two to five days, it is very rare to encounter an instance in practice where it corresponds to the longer period. In most cases it is two or three days. Some au

thorities claim that there is practically no period of incubation in this connection, the sore immediately beginning to manifest itself. When such rapidity of development seems to have occurred, it is probable that the sexual act occasioned an extensive abrasion, a sore in itself, and that the chancroidal virus implanted on the raw surface began to manifest itself before the original lesion had had a chance to heal.

With chancre the period of incubation is more variable and indefinite, although, in most instances, ten to twenty days, yet it may require thirty or somewhat more. Some authorities put the extreme limit at seventy to ninety days. I am not personally aware of having seen any instances in which I was thoroughly impressed with the fact that the true incubation corresponded to such long periods, although on several occasions patients have come to my notice stating that periods similar to these had elapsed after intercourse before a subsequent chancre had been noticed.

In such instances it should also be borne in mind that the patient may have erred either as to the date of his last sexual exposure, or in failing to detect the presence of a chancre during its early stage of development. Although most men careful of their person have their attention attracted by a chancre in its early stage of development, some do not, while those especially careless and non-observant, may, on rare occasions, harbor such a lesion through all its stages of development and recedence without knowing it. The case is somewhat different, however, with women, since a considerable percentage of them first become aware that something has gone wrong only with the advent of secondary symptoms, the fact that chancre in connection with their genitals had previously existed having wholly escaped them. This difference with respect to the sexes is not due to the fact that man is more naturally observant than woman, but to the fact that in the former sex the genitals can be seen with ease, and, as a rule, are brought into view so as to allow thorough inspection at each act of urination, while in the latter, the parts can not be individually viewed except by reflected light.

The preceding remarks apply only to genital chancres, and to instances in which the primary pathological developments have been slight. In all instances, of course, wherein the initial lesion is markedly developed, the attendant tumefaction, induration, necrosis and ulceration produce sufficient subjective sensations to attract an individual's attention in the absence of an ability to employ direct inspection.

Pain, a prominent characteristic of chancroid, renders the harboring unawares of that lesion very improbable. In fact, as a rule, a woman is especially apt to take cognizance of its existence, since the chafing to which her genitals are subjected while walking, together with the urinary dribbling to which they are particularly exposed, seem to intensify the effect of the contamination.

Although the site of chancre on the genitals may be anywhere, still certain spots are especially favorable for inoculation. In connection with the male, the majority of these are on the mucous membranous portion of the foreskin. The part of the membrane which is especially liable to tear or become abraded during coitus is that just back of the line of junction with the corona, and that covering the frænum. Former attacks of balanitis have many times left the mucous membrane thickened, inelastic, and its folds agglutinized in the first of these positions, thus causing a surface lesion as the natural result of the tension to which the part is apt to be subjected, while an entrance is being effected. The prominence of the second part exposes it especially to the action of friction.

A site perhaps next in order of frequency is along the line of junction of the cutaneous and mucous surfaces of the foreskin. In a considerable number of individuals with long foreskins, the apertures of which are narrow, the line of junction when the foreskin is retracted, and the penis erect, is rendered so taut that longitudinal splitting of its epithelial structures in numerous places is apt to

occur.

The male meatus and the fossa navicularis are also unusual but important sites for both chancre and chancroid. The term urethral chancre is often employed

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