biliousness if you like, are always associated with a greater or less amount of septic infection. Evidence obtained from the clinical condition and from the examination of cases surgically treated bears this out. Not only do we find an acute inflammatory condition of the mucous membrane, but in a large majority of cases, ulceration as well. In more severe cases still peritonitis is set up, and adhesions are formed between the peritoneum covering the gall bladder and that covering adjacent surfaces. The pathological cycle, in fact, is not by any means very unlike that of appendicitis. Naunyn has shown that cholesterin and calcium, the chief constituents of bile, are formed in the mucous membrane of the bile passages. Gilbert and Fournier, too, are of opinion that gall stones derive their origin from this source, and that the mucous abundantly secreted, and the desquamated and degenerated epithelium unite with pigments to form insoluble compounds. So that although gall stones a second stage in the pathogenic cycle may again cause attacks of cholecystitis and biliary colic, these attacks are often present when no gall stones can be found. It is only when patients experience intense pain that we look upon the case as one of biliary colic, but it is more than probable that many cases of acute dyspepsia, or what are termed attacks of the liver or biliousness are really attacks of cholecystitis possibly, at times, associated with gall stones, or occasioned by an ascending catarrh originating in a gastroduodenal catarrh. Naunyn who is if anything an advocate of medicinal treatment admits that in the great majority of so-called cures, one has to do with a cure for the time of the septic complications only. Kehr and Mayo hold similar views, and so I am sure must anyone who has given to this subject his thoughtful consideration. It is true that patients sometimes go on for a considerable length of time after an apparent cure of an attack of cholecystitis, but this is by no means a guarantee that he has been cured. I grant, too, that these cases do not warrant our recommending interference where such a prolonged abeyance of symptoms exists, simply because we are not in a position to say whether gall stones or some such possible sequela of cholecystitis exists. Although it is admitted that gall stones may form in the bile ducts, the bulk of evidence goes to show that the vast majority are formed in the gall bladder. This is what one would expect, for a running stream such as one finds in the bile ducts would not be so favourable to their development. Again, so far, I know of no case where a second operation has been needed for the removal of gall stones, and inasmuch as in almost every case either the gall bladder has been stitched well up into the abdominal wound or surplus material removed or the whole bladder or its lining membrane removed, it would seem that this in itself has a marked influence over the prevention of stasis of bile in what is left of the gall bladder, and in a way presumably influences the prevention of the fresh formation of gall stones. I have not been able to obtain any definite evidence on this point but in cases where there was a probability that stones had formed in the ducts, it would be of some interest to know whether pockets did not exist in which stones could gradually be formed. Let us look at the pros and cons of surgical versus medical treatment. Gall stones are almost always formed in the gall bladder. The operative treatment in good hands shows one per cent. of deaths. Recurrence must be very rare, I certainly do not know of a single case. If the stones pass into the ducts operative treatment gives us as much as ten per cent. of deaths, though I think that this will probably be greatly lowered. While gall stones remain they may give no trouble, but they are always liable to and frequently do give rise to septic attacks and malignant disease, and more rarely to perforation. All of these prove themselves to be a great menace to life. I cannot, from my own experience give precise data as to the frequency with which gall stones cause cancer. Within the last two years I have met with six patients under my own observation who died of cancer of the gall bladder following on cholelithiasis. Two of these I thought I had cured with olive oil six or seven years ago. Klob and later Frerichs, Klebs, Hilton Fagge and others have testified to cholelithiasis as a cause. Courvoisier found gall stones in 74 out of 84 cases. Brodouski found gall stones in 40 consecutive cases of cancer of the gall bladder. It is true that cholelithiasis is no newly discovered disease and for that reason there is great difficulty in convincing men that it is not the common place painful but comparatively harmless disease we once thought it. Jaundice, which was so often looked upon as the only feature wanting to clinch the diagnosis is considered by Naunyn to be present to the extent of giving a urinary reaction in only one-half the cases, and this probably means that occasionally cases have had repeated attacks of biliary colic sufficient to give some stones at all events an opportunity of getting into the bile ducts. Kehr is very emphatic in stating that 80 per cent. of gall stone cases do not suffer from jaundice. This leaves a large percentage of cases difficult to diagnose, and which were once attributed to bilious attacks, gastritis, dyspepsia, malaria, and other diseases associated with acute abdominal conditions. The grave sequelæ which are apt to supervene are well exemplified in the series I present to you, and I think that the most conservative physician can hardly insist that he is right in allowing a condition of affairs to remain in a patient's abdomen which may at any time produce intra-abdominal, local, or general sepsis. The state of affairs is this. If a patient has gall stones there is a 1 per cent. of risk open to him if they are removed from his gall bladder, and practically no chance of recurrence. If they are left he must be prepared to take the various risks with which we are acquainted. On the other hand you might remark how often can any of us say positively that gall stones are present? Very rarely indeed, but we do not necessarily operate for gall stones, but for a cholecystitis which is deemed to be sufficiently severe, either from the severity of this one attack or the frequency of the attacks to need operative interference. Biliary colic is almost always due to cholecystitis. Cholecystitis is a septic condition sometimes amenable to medical treatment. If, notwithstanding treatment, attacks recur, then, whether we think gall stones are present or not, the bile passages should be examined, the cause if possible discovered and rectified. If there be any obstruction to cystic or bile ducts it should be removed. If the gall bladder be affected the lining membrane or the whole bladder should be removed just as we should remove an appendix, for the pathological conditions are very similar. I shall be brief on the question of the methods of treatment. Preventive treatment should confine itself to keeping in check those causes which are likely to produce gastroduodenal catarrhs. Olive oil I have used greatly, and at times with good results, that is to say this oil, in conjunction with podophyllin, gave frequent motions, and both the patient and I were delighted to find a lot of green lumps we called gall stones. The fasting and purging relieved the inflammatory conditions, and the attack passed off. The patient called it a cure. I was after a time not quite so sanguine. Cholagogues, with a view to increase the flow of bile, can be of little service. It is not increase in quantity of bile we need, but increase of pressure. If the pressure is increased in the ducts very little above normal, the secretion of bile is prevented, so that cholagogues can only act as ordinary brisk aperients. My own impression as to the best method of treatment is this. During the attack give opium and belladonna in order to relieve the pain and spasm. As soon as possible give large doses of salines, preferably, or any other aperient by the mouth, or, if they are not retained, give them by the rectum. Salines produce free watery evacuations and in this way deplete the inflamed part. If the salines be given warm so much the better. The application of heat externally is soothing, and leeching also appears to be of service. The surgical treatment I have already touched upon. The operative treatment of cases of cholecystitis and cholangitis is at times very simple, but he who attempts to operate on the gall bladder and bile ducts must be prepared for anything, and at times, if he do his duty, he will find that he is face to face with one of the most difficult tasks in surgery. I have heard of cases of congenital absence of the gall bladder, but I have never met with one. I am inclined to think that greater experience or a more effective search would very much increase their rarity. Before concluding, I would like to ask-Is it not patent that the majority of us in dealing with cases of cholecystitis and cholangitis have shown too little thoroughness, and have profited too little by our knowledge of the misery and mortality which follows so often in the wake of these cases, and have we not clung too long to the crude and unscientific treatment of our fathers? After all, what is it we must seek to do for our patients? Is it not to restore them to health as completely, as speedily and with as little risk to life as possible? If surgery can claim such a large percentage as 99 in early cases, and can, so far as we know, promise complete amelioration, then what object is gained by temporising at times for days and even weeks with a poor wretch who is in constant pain, and who, even if he does recover, recovers with the pleasant prospect that some day he may have it all over again. Even these few cases show what great risks several of the patients ran, and what a small shred of hope the operator often clings to when struggling to bring the case to a successful issue. The dangers of operative treatment have hitherto no doubt deterred many men from recommending their patients to submit to surgical measures, but improved methods and experience in this class of work have made such treatment in careful hands, infinitely preferable to the many uncertain, tedious, and more painful methods adopted by those whose conservatism or inherited convictions will not allow them to take advantage of the more efficient line of treatment which such cases merit. A thorough examination into the already active pathological processes in the living subject will not only solve many a clinical riddle, but will give to us the means of saving many a life. I am afraid that I have told you nothing new to-night, but I shall be content if I have been able to place these few cases before you in such a way as to induce you to look upon this subject with some increase in your appreciative interest. CHOLECYSTOTOMY, FOLLOWED BY CHOLE- By R. Steer Bowker, M.R.C.S., L.R. C. P., M. R., æt. 42. Living in Sydney; was admitted to Sydney Hospital on 6th June, 1900. She was a miserable looking woman, appearing many years older than her stated age, having evidently lost a deal of weight, being very jaundiced, almost to a mahogany colour; the conjunctivæ were deeply jaundiced, giving her the appearance of a woman with malignant disease of the liver. Her history was as follows:-She was well up to January, 1900. On February 1st she was suddenly seized by violent pain across the lower part of the abdomen. which lasted for about 12 hours, she vomited freely and felt relieved; the pain was not accompanied by fainting, sweating, or collapse. She went to bed and remained there for three or four days, and still felt weak and ill. She had an irritation of the skin, and shortly be came jaundiced; this jaundice has gradually increased in intensity. She has had all along dull aching pains all round the upper part of the abdomen, never acute. No attacks of biliary colic, and she only vomited on the one occasion. She has lost weight; she was about 11 stone in January, now is about 8 stone. There has been no hæmatemesis or melæna; bowels confined, motions very pale; no pain or frequent micturition, urine is dark. She has no cough, but slight dyspnoea on exertion; feet used to swell. Past History.-Previous to onset of illness, she was very drowsy for some weeks. There is no history of alcoholism or of the use of strong condiments. She had an attack of inflammation of bowels when 12 years of age. Family History-Good. Present condition.-Temperature irregular, occasional rise to 101° or 102o. to Digestive System.-Tongue dry, furred; no vomiting or nausea; always thirsty; appetite fair; bowels very confined; no melæna, stools clay-coloured; abdomen moderately easy to examine, slightly tender beneath right costal margin. Liver dulness from fifth space costal margin, 4in. Stomach resonance lower than normal. Flanks resonant, spleen not enlarged. Circulatory, respiratory, and other systems are normal. She was tender on deep pressure, and the muscles stood on guard, and it was impossible to feel the gall bladder, so we concluded it was not very distended; this pointed to gall stones as the cause of the obstruction, and Dr. Jamieson was of opinion that the trouble was due to a stone impacted in the common duct, though the sudden onset, without any attacks of biliary colic and the steadily increasing jaundice not being intermittent, was rather against cholelithiasis. However, we agreed as to the mode of treatment, and decided to cut down and explore, the patient herself being very anxious for the operation. She was put on calcic chloride gr. xxx, t.d.s. 13th June. She was given a hypodermic injection of morphia and atropine, and ether was the anesthetic used. I could now distinctly feel a linguiform prolongation of the liver, with a distended gall bladder. An incision was therefore made over the tumour, and a very distended gall bladder found, the walls of which were very thin in places and thick in others; ahard greyish nodule was found on the surface of the liver, and on the under surface were also seen several lines of fine yellowish nodules running in the direction of the lymphatics; all round about the common duct was matted, and the duct hard to palpate, but no stone could be felt. What was at first thought to be a stone was found to be an enlarged gland in the curve between the cystic duct and the gall bladder. I removed a small nodule from the liver for microscopic examination. There was such a lot of matting that I could not make out the parts near the duodenal opening of the duct; the gall bladder was then packed round and an exploring syringe introduced into its lower end, and a quantity of pus withdrawn. The bladder was freely opened and explored, but no stone could be found; it was then stitched in the usual way to the wound. 14th June.-Microscopic examination showed the growth removed to consist of young fibrous tissue only. I was glad of this, as I was afraid, by the appearance of these nodules, that the cause of the obstruction was malignant. 2nd October.-Patient is a different woman. She eats well, looks well, feels well, has gained considerably in flesh, but complains of the fistula, which discharges an enormous quantity of bile each day, as being an intolerable nuisance to her, and begs to be freed from it; so I explained to her the risk of a cholecyst-enterostomy, as I considered that the only operation which could give her relief, and she determined to undergo it, to get rid of her infirmity, so, after consultation, I decided to try it. 17th October, 1900.-Hypodermic injection of atropine and morphine was given, and, under ether, an incision was made surrounding the old scar with an ellipse, the sinus was plugged with wool, and dissected from amongst the tissues, until its junction with the gall bladder was reached and freed from the abdominal wall; this was clamped to prevent the escape of bile during further manipulation. The gall bladder was very atrophied, in fact was little more than a tube, and was firmly fixed in a mass of omentum, and a great many adhesions had to be broken down, and another search for gall stones instituted, but none could be found, a probe passed as far as possible through the bladder, etc. The parts about the common duct and head of the pancreas were very matted, and it was impossible to thoroughly palpate the common duct, a condition which was present at the former operation. At this time I did not know of Weller van Hook's method of air distention, or should have tried that. The obstruction (now that we knew that the growths on the liver were inflammatory) being probably due to interstitial pancreatitis, the only thing left was to join the bladder to the intestine. The adhesions about the duodenum were so great and so dense, and the ascending colon so ready to hand, that I deter mined to join the gall bladder to that viscus, lying as it did almost in contact with its lower surface, so that I closed the opening in the lower end of the bladder with catgut, made a fresh opening in it's lower surface, and joined it by means of a small Murphy's button, to the ascending colon just below the hepatic flexure; the abdominal wound was then closed with through and through sutures of silkworm gut, and dressed in the usual way. 18th October.-Temperature 98-4°, pulse 74, no distention, slept well, is very sleepy. 26th October.-Doing well, but has considerable diarrhoea. 1st November.-Diarrhoea has stopped. 27th November.—Went to the Walker Convalescent Hospital to-day; wound quite healed and firm. Is very well and very grateful, but has not returned the button. I saw the patient recently, and she was then very well indeed, her only trouble being a small she had become so enamoured of operations hernia at the lower part of the wound, and that she wished to have this at once attended to. I advised her to leave it for a little, though the temptation to have a look at the seat of anastomosis was considerable. in this case. jaundice, coming on with very marked acute pain in the epigastric region, and lasting for colic; the jaundice intense and increasing, and 12 hours; no attacks before or after of biliary not intermittent, and by ordinary examination no gall bladder to be felt; tenderness under right costal margin, and the right rectus on guard, with a deep, dull, aching pain near the navel, almost constant. By the jaundice there was evidently some obstruction to the common duct; by the fact that this jaundice was constant, the obstruction was evidently fixed, that is not movable; by the fact that there was no colic, evidently the gall bladder gave up the fight of trying to overcome the obstruction, and ceased to painfully contract, and distention considered it futile, that is its muscular walls instead of contraction took place. Now all this happened suddenly to an otherwise healthy woman. She was five months in this condition without gaining ground, but on the other hand diced, and had an erratic temperature, and was losing weight, and becoming more jaunalways a deep-seated, dull, aching pain in the epigastrium, and no tumour to be felt. Remarks. Now with regard to the diagnosis Here we had a case of extreme The proper treatment, no doubt, would have been to have examined her under an anesthetic, for in all these cases it is important to know the condition of the gall bladder, and, mostly without the aid of sleep, impossible to get this information, and in the diagnosis a deal depends on this, for there are certain aphorisms laid down for our guidance, and generally pretty correct :— I. A distended gall bladder without jaundice points to obstruction in the cystic duct. II. A distended gall bladder with jaundice points to fixed obstruction (tumour) in common duct, stricture, etc. III. A contracted gall bladder with jaundice to movable (not constant) obstruction such as a stone, in common duct, owing to its ball valve action. (Fenger, Robson, and others.) The gall bladder in this latter case tries to dislodge the obstruction which is not constant, and its muscular walls become hypertrophied, and there are constantly recurring attacks of biliary colic, ceasing when the stone falls back in the dilated duct, with intermittent attacks of jaundice, more or less, as the stone allows the bile to pass, and the bladder eventually becomes thickened and contracted. On the other hand, if the obstruction is fixed, as by a fixed stone, or an increasing tumour, or inflammatory product, or a stricture, the result of an ulceration with contraction, then the gall bladder, finding it useless to fight against the obstruction, distends, and is, as it were, thrown out of commission; and, if poisoned, fills with pus, or, if not, with bile, which becomes decolourised, and with mucus from the mucous lining of the walls. Now, had this woman been examined under an anæsthetic, we should have known (as we did later) that she had a distended gall bladder, with constant and increasing jaundice, and this would, in itself, have rather pointed to the fact that the obstruction was constant, and so probably not caused by a stone, and as stones are generally formed first in the gall bladder (on account of the conditions necessary for their formation being existent in the gall bladder more so than in any other part of the bile tract), there would have been painful attacks before the last sudden one in the passage of the stone along the cystic duct; but we get no history of there having been any, and at the operation no stone could be found. Hence it looks as though the cause of the obstruction was an adhesion or pressure of some sort, malignant or inflammatory. The attack came on too suddenly for malignant disease, so that it probably was inflammatory. Probably the cause was interstitial pancreatitis, with cholangitis and empyæma. A cholangitis alone or desquamative angio-cholitis would hardly account for such fixed obstruction, lasting after the gall bladder and ducts had been thoroughly drained for four months. Now this and other cases which I have had have made me think a good deal about jaundice and gall stones, and teach that one can have a good deal of jaundice without any gall stones, and also that one can have a good many gall stones without any jaundice. One in his earlier days used to think of jaundice and gall stones as always running in couples, but this is far from being the case. The fact is that when gall stones cause jaundice the case is pretty serious, and requires very often a very serious operation indeed to give relief, for I do not know of any more formidable operation than a choledochotomy, with all the parts out of relation and matted together by inflammation, as the result of a stone or stones which will not pass into the duodenum, even though the patient has taken all the oil which has been ordered to him by his different physicians. Some people have luck-some people always will have-but ordinary mortals cannot depend on that; the stones, if left, have a fashion of jumping the fence, or rather of not making themselves scarce by the orthodox exit, even when supplied by oil. I remember being asked to see in consultation, with a view to operation, a lady who had suffered from gall stones for many years. She had very violent pain, and evidently some peritonitis; she had passed a few small stones, so that we decided not to operate immediately, but to wait a little; in the meantime she vomited some large stones, one very large one and a lot of others had passed by the rectum They had probably slowly ulcerated into the stomach and become voided, but she was lucky; they might just as easily have ulcerated through into the abdominal cavity and set up a fatal peritonitis. Now this patient had lived for years on the brink of a precipice, suffered constantly recurring attacks, in the constant danger of death, or what was much worse- -the danger of cancer. She had the good luck to come out all right, but how many can depend on that, and if in the end an operation had been necessary it would have been a most difficult and dangerous one. I have operated upon a great many cases of gall stones, and I can say that the only case that was not cured was one of very long standing-20 years-then on his last legs from pain, cholcemia, and exhaustion, with stones impacted in his common duct; I removed seven as the result of a long, tedious, and difficult operation, but he died in a short time from the shock, added to his already cholomic condition. This was the only case I ever lost, showing what a safe operation the operation on the gall bladder is; and I don't think anyone should leave a painful and distended gall bladder in the hopes that it may get well-for that is what it comes to-and watch a stone, which is literally in his |