19 were considerably diseased I excised it, after satisfying myself that the common duct was free. An enlarged gland which lay immediately below the neck of the gall-bladder was also removed. Neither in this nor in the gall-bladder was there any sign .of growth. Some caseous nodules were found in the gland, but no giant cells. I put a ligature around the cystic duct, which was quite small, and closed the wound with a drain in the space formerly occupied by the gall-bladder. On Oct. 31st it was

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... oticed that there was a little bile escaping from the drainage-tube and that the patient was jaundiced; her stools were claycoloured and the urine contained bile. The discharge of bile from the wound became very free, :and the jaundice which was complete continued. I was at a loss to explain this unusual combination of symptoms and to connect it with my operation, unless I had left behind a stone in one of the hepatic ducts. So on Nov. 18th I reopened the wound and found the cut end of the cystic duct patent, and bile flowing freely from it. A probe passed easily into each hepatic duct, but I failed to detect a stone in either of them. I could not pass a probe along the common duct, but I could not detect any thickening or block in the duct in any part of its course. Amid much that was uncertain there was one undoubted fact-that the bile was flowing freely from the end of the cystic duct-so I determined to deal with this by uniting the end of the duct to the duodenum. There was less than half an inch of the cystic duct left, I therefore did not enlarge its orifice by slitting up the duct, but making a tiny incision through the coats of the duodenum I united the cut end of the duct to it by a double row of sutures. The wound in the abdominal wall was then closed above and below a drain. For a few days there was a slight escape of bile; this soon stopped, and the wound healed soundly. On Nov. 20th the jaundice was noticed to be distinctly less, and a motion passed on Nov. 21st was dark brown in colour. From this time the jaundice rapidly lessened, the motions continued of a normal colour, and the patient left the hospital quite convalescent on Dec. 12th. The interest of this case lies in the fact that a patient who for years had had gall-stones, but without jaundice, developed jaundice immediately after the removal of the gall-stones and of the gallbladder, and that the jaundice was unrelieved by the free escape of bile from the divided cystic duct. It is clear that something occurred at the operation which produced an obstruction or obliteration of the common duct. This was not the dis-I placement of a stone from the cystic duct into the common duct, for not only was no stone found at the second operation, but the cystic duct was of its normal size-just admitting a probe-and had evidently never been distended by the passage of a stone large enough to block the common duct. In this respect the case reminds me of a patient upon whom I operated three years ago. She had a cholecystotomy done by another surgeon some years previously. I was called to see her for recurring attacks of jaundice with fever and acute epigastric pain. Expecting to find a stone in the common duct, I operated and found dense adhesions in the midst of which I opened a dilated common duct; this was stenosed lower down, but I was able to trace the duct through the adhesions and restore the continuity of its two portions. But far more interesting than the blocking of the common duct as a sequel to cholecystectomy is the , association of deep jaundice and dark bile-loaded urine with free escape of bile from an external fistula. I can offer no satisfactory explanation of this, nor can I explain how turning the bile again. into the duodenum sufficed to remove a jaundice which was not benefited by its external escape. I was greatly relieved to find that my second operation was successful in spite of any adequate explanation. VISITING PHYSICIAN, MILL ROAD INFIRMARY, LIVERPOOL. TUBERCULOUS rheumatism was first described by Poncet, of Lyons, and other French physicians, such as Berard, Maillant, Bezancon, and Griffon, have reported cases from their own researches, but so far British physicians have not described the condition in detail. The articular lesions in infective diseases, such as gonorrlicea, dysentery, syphilis, pneumonia, &c., are quite different from the pseudorheumatic arthritic lesions observed in some forms of tuberculosis. From an observation of over 6000 cases of pulmonary tuberculosis under my care in hospital and elsewhere, I have not met with a single case of tuberculous rheumatism-at least, it was not recognised as such; and although it is very common to see cases of tuberculous arthritis attacking one or perhaps more joints, it is most rare to meet with a multiple arthritis of the smaller joints in the hands, fingers, wrists, and ankles in the course of tuberculosis. The subject of this paper is a young lady, aged 19, of healthy parents. She has several sisters, all of whom are healthy. I am told that she was always, as a child, very fond of milk, and drank large quantities. At the age of 13 she first developed tuberculous glands in the left side of the neck. These gradually spread down to the clavicle, into the submaxillary regions, and to the right side. The infection was slowly progressive, until both sides of the neck were much swollen and very painful. Her general health became seriously affected and she lost weight rapidly. Every remedy was adopted, but nothing seemed to check the infection. At last, five years after the first onset, the glands in the original focus showed signs of breaking down, and it was decided to open and remove the contents of all the suppurating glands. This was done by Mr. W. Thelwall Thomas, but it was impossible to remove any glands, so firmly were they fixed to everything in the neck. A month after the operation the patient developed a painless, rapid effusion into the right wrist-joint, followed in a week by a similar condition in the left wrist, and followed again by swelling of all the metacarpo-phalangeal joints of both hands. There was very little pain, but the temperature was high, 102° F. at night and 99° in the morning for 10 days. Salicylate of soda had no effect whatever either on the temperature or joints. The right wrist was aspirated and half an ounce of fluid removed. Very careful cytological examinations were made in order to detect tubercle bacilli, but none could be demonstrated.