and a sense of pressure in the epigastrium." The skin of the face first becomes pale and yellowish, then yellowish brown. The conjunctiva is tinged yellow. The urine is scant with excess of uric acid. Bile pigment in the urine is frequently absent at first, but later usually appears in small quantities.

When a stone leaves the gall-bladder and is lodged in the duct, a severe pain or billiary colic is usually the result. If lodged in the common duct, jaundice will invariably follow the attack, and both pain and jaundice are likely to continue as long as the obstruction exists. If the stone be lodged in the cystic duct, little or no jaundice will be present, and the pain may become tolerant and the patient go through a long period of semi-invalidism before the real cause of the trouble is discovered and removed. It is not uncommon for gall-stone patients to pass through years of suffering thinking that their trouble is with the stomach. If there has been no colic at the beginning of a slowly advancing jaundice, the trouble is probably due to inflammatory or malignant obstruction, rather than to gall stones. When the duct grasps the stone, which is leaving the gall-bladder, active peristalsis of the bladder and of the entire alimentary canal begins. The pain may be referred to other portions of the abdomen and the real cause of the trouble be overlooked temporarily. In Keeting and Coe, page 659, mention is made that in post-mortem examinations on patients who have died after ovariotomy, gall-stones and distended gall-bladder have been frequently found where there had been no symptoms during life referring to this trouble. The question arises, might not some of the symptoms, for which the ovariotomy was performed, have been in part due to the trouble in the gall-bladder instead of in the ovaries alone?

When either the common or cystic duct becomes obstructed, the gall-bladder usually fills and distends until it is quite large. If the obstruction is complete and is in the common duct, the fluid in the gall-bladder will be mostly bile and the distention will likely be rapid, as the normal amount of bile excreted daily is about one pound. If the obstruction is in the cystic duct, the enlargement is likely to be more gradual and the contents of the bladder will be a viscid clear colored liquid, which is excreted from the glands of the gall-bladder itself. If the stones are firmly impacted, or if there is much inflammation going on, pus will be present, with septic symptoms more or less severe.

It is not uncommon to find the gall-bladder so distended as to hold from four to eight ounces, and in this condition it has frequently been mistaken for a floating kidney. Occasionally both are present.

One point of difference is that a floating kidney is usually quite movable and especially posteriorly, while the motion of a distended gall-bladder is more restricted and more anterior, and in the arc of a circle having the normal position of the gall bladder for its center. If the abdominal walls are not too thick, a diagnosis can frequently be made by placing the patient in the dorsal position with knees flexed, the left hand of the examiner is placed underneath with finger tips pressed up just below the floating ribs on the right side, his right hand placed on the abdomen over the tumor. In this position fluctuation can frequently be felt. If the bladder is tightly distended, however, it may appear as hard as a kidney, but will not allow of the same freedom of motion.

As to treatment, you are all familiar with the different medicines and methods which have been suggested and tried in the last few years. Perhaps the use of olive oil, in from four to ten-ounce doses, has had more advocates, and, judging from the literature on the subject, has given better results than any of the others. This cannot be relied upon, however, as being of much value, and especially in cases where the stones are very large or are firmly impacted, and it is usually very disagreeable to the patient.

When should operation be performed? Robert Abbe of New York, in Dennis' Surgery, page 569, says: "The surgeon does not do his duty by the patient if he waits for him to be nearly exhausted. The results of operative relief are so uniformly good in uncomplicated cases that to await is only to invite com plications."

Carl Beck, in New York Medical Journal, May 8, 1897, says: "I would advise the operation as follows:

"1. Whenever the diagnosis of acute cholecystitis is made, cholecystotomy should be performed without delay.

"2. Cholecytotomy should also be performed in chronic hydrops of the gall-bladder.

"3. Whenever acute colicky attacks in the region of the gall-bladder, combined with fever, return for a second or third time.

"4. Whenever jaundice is present for more than four weeks.

"5. In gall-stone ileus.

In all obscure cases when inflammatory symptoms in the region of the gall-bladder resembling peritonitis turn up, exploratory laparotomy is indicated."

I believe to explore is by far the safer plan, and that in operating, where it can be done, it is better to attach the gall-bladder to the abdominal peritoneum and drain it externally, especially if there is any question of its containing infective material. Where

this cannot be done, cholecystenterostomy is the proper procedure, joining the gall-bladder to the small intestine by prefer ence or to the colon, if more convenient. This can best be done by means of the Murphy button. The gall-bladder may be removed if necessary, provided the ducts can be left intact.

year.

I wish here to report three cases operated during the past

Case I.-Mrs. M., age 44, American born, mother of three children, youngest 14 years. Gives history of having suffered from attacks of indigestion for about twenty years. I saw her first in December, 1897, in an attack which passed away very readily. At this time I made a diagnosis of gall-stones. There were no more attacks until July 2, 1898, at which time there was another coming on with severe, sudden pain in the right hypochondriac region, followed by fever, the temperature reaching 103 degrees F. Chills were present. I was called and gave a hypodermic injection of morphine and atropia to relieve the pain. A hard tumor about the size and shape of a normal kidney could plainly be felt in the right hypochondriac region. The intestine was anterior to the tumor. The tumor could be moved more freely than is the rule with a distended gall-bladder. There was no jaundice. A little albumen, pus and blood were present in the urine, but no sugar. Septic symptoms began to show them. selves and it was decided to operate. Dr. Leonard Freeman of Denver, saw the case with me and assisted me in the operation. Operated in St. Luke's Hospital, July 6, 1898.

We were unable to exclude movable kidney. Made an exploratory incision four inches long in the right hypochondriac region, going through the outer edge of the rectus muscle. Found a hard mass resembling a kidney. On further examination, the kidney could be felt in its normal position. Loosened some peritoneal adhesions, which were not firm, turned patient on her right side, walled off the abdominal cavity with gauze, and with two fingers inside of the abdomen to hold the gall-bladder up to the opening, made an incision in it about an inch and a half in length, and removed thirty-eight stones and about eight ounces of pus and clear viscid fluid. Several of the stones were wedged together in such a way as to completely obstruct the duct and were somewhat difficult to remove. Cleaned out the gall-bladder and stitched its peritoneal surface to the parietal peritoneum, put in a drain of washed-out iodoform gauze and closed the remainder of the wound with interrupted sutures of silk-worm gut. A few sutures on either side were taken through the abdominal wall and the peritoneum of the gall-bladder in such a way as to assist in rolling the peritoneal surfaces of the opening cut in the gall-bladder together, to facilitate final closure.

The discharge of pus and bile from the wound was quite free for about ten days, when a pressure pad over the wound, held in place by an adhesive plaster, caused plenty of bile to appear in the stools.

2.-Gall-Stones removed from Case II. 3.-Gall-Stones removed from Case III.

The edges of the wound were then scarified under cocaine and the wound closed with fresh sutures. The albumen disappeared from the urine and the patient made a rapid recovery and has been in perfect health ever since.

Case II. I was called by Dr. Sheets of Denver, October 24, 1898, to see Mrs. W., age 41, mother of one child, 6 years old. Has had occasional paroyxsmal pains in right side for eight or ten years. Had been treated by different physicians for stomach trouble, and once only, a diagnosis of gall-stones had been made. Temperature was 104 degrees F., with rapid pulse, chills and profuse sweats.

A very tender tumor could be felt in the region of the gallbladder, which extended down almost to McBurney's point. There was a large quantity of albumen present in the urine, with epithelial and hyaline casts, but no sugar. There was no jaundice. Consent to operate was not obtained for two days on account of husband being away from home. Temperature kept

up. Had patient prepared in her home for operation, and on the arrival of the husband, the morning of October 27, removed to St. Luke's Hospital and operated.

Chloroform anaesthesia was used and the operation required about forty-five minutes. Found adhesions covering most of the gall-bladder. These were not difficult to separate and when freed, the gall-bladder came easily into the incision. Opened and drained, as in Case I., and closed wound the same, except the sutures were so placed that when tied, they would roll in the edges of the gall-bladder wound, bringing its peritoneal surfaces together.

These sutures, instead of being tied separately on either side, went entirely across, including both sides of the abdominal wound, as well as the gall-bladder, and two of them were left without tying until it was desirable to permanently close the gallbladder and abdominal wound, as in cut. About seven or eight ounces of pus and 134 gall-stones were removed. The largest of these stones was imbedded in the common duct in such a way as to completely obstruct it. This stone weighed sixty-eight grains.

A.-Gall-Bladder brought up in wound.

B.-Peritoneum in ends of wound, closed by continuous cat-gut suture.

D.-Sutures of worm silk-gut for closing abdominal wound,

E.-Sutures left at time of operation-for final closure of drainage opening.
F.-Opening in gall-bladder.

Temperature went down immediately and recovery was rapid. The abdominal wound was closed in one week. The