In one there were stones in the gall bladder in the common hepatic and also the right and left hepatic ducts. The common hepatic duct was opened and stones some fifteen in number were removed. In the fourth stones were removed from the common hepatic and common bile duct.

The fatal case I have already mentioned occurred in a woman of 54 with malignant disease of the gall bladder. She had intermittent jaundice and very great pain. I thought that I might be able to relieve her by getting rid of the stones. I was not aware that she was suffering from malignant disease before I operated. At half past one she was seen by Dr. Heggaton and seemed well with a pulse of 104, and she died shortly after three. In none of these cases did I make any attempt to suture the bile duct. In three of them so matted were the surrounding structures it would have been impossible to do so. In the other two it was possible. A rubber drainage tube was placed with one end on the opening in the duct, and outside and inside this tube were placed gauze drainage wicks. If septic symptoms had subsided the drainage was discarded after a few days when a firm lymph track had been established.

It is well known that linear incision of a mucous track like the urethra heals with a fine linear scar, and is not followed by stricture. Arguing from this I acted as I did, nor have I had any reason to be disappointed with the result.

Suture is unnecessary and often impossible. It requires a larger incision, necessitates a greater amount of handling and materially prolongs the operation. Suture also offers a fair chance of diminishing the calibre of the duct. These cases necessitating choledochotomy are often associated with a pathological condition of the bile ducts due to backward pressure and infective processes, so that drainage, free drainage of the ducts is an absolute necessity and a sound surgical procedure.

Even in those cases where men have sutured, the duct leakage has frequently taken place, and in some cases where suture has been adopted without drainage, leakage has occurred and has been followed by death. It is evident then that suture of the duct is not necessary, and unless it be backed up by good drainage, it is likely to be productive of fatal results. Mayo reports eleven cases of choledochotomy. In four he sutured and drained, and in the re maining seven he did not suture. All recovered.

I shall next direct your attention to the

acutely septic cases. There were eight, and two of them died. One, a man of 38 years, became suddenly ill with rigors. He was ill for about ten days before I saw him. He was slightly jaundiced and tender over the gall bladder and hepatic region. He had no gall stones, and though I drained his gall bladder bile never flowed freely, and his condition was in no wise abated. He merely became less jaundiced, and died in about three weeks time. There was no post-mortem I do not know what was the origin of the attack-it was probably intestinal. A man of 50 years had an attack of biliary colic twenty years ago, and another six years after that. During the past twelve months the attacks have been very much more frequent. He was continuously ill for three weeks before admission. He had rigors about every eighteen hours after he was admitted to hospital. He was operated on the third day after admission. I admit that this was three days lost. On the last day he for the first time showed some slight jaundice. He had very marked tenderness over the gall bladder. His pulse was 130, and his temperature 102°, and he looked very ill indeed. After some difficulty his gall bladder was found deeply situated and hidden by omentum and transverse colon. It was extremely small, and distended with gas in the upper part, so that I was almost persuaded that I was dealing with intestine. On opening it gas escaped, and in the lower part there was about a teaspoonful of very fœtid pus. No gall stones could be found. He recovered rapidly, but returned in two months' time with dragging pains and a history of a rigor. I opened, and found no evidence of gall stones in the ducts, but there were necessarily many adhesions which I separated. He at the present time looks well, but he still has pain which he asserts is not at all like the old trouble, and is, I believe, to be attributed to adhesions, inasmuch as he is gradually getting better. Harris states that this often occurs for some time after operating on shrunken gall bladders. In one other case did I experience a like result. The pains left gradually and have not returned after eighteen months. Four other cases were operated on, when rigors and high temperature, and offensive purulent material and gall stones were found in the gall bladder. One of the patients with malignant disease of the head of the pancreas gave a history of old attacks of biliary colic, and no stones were present. She was extremely jaundiced. The other was slightly jaundiced, but the whole of the pancreas was involved. The bile duct was affected by pressure only.

It certainly seems odd that in these two cases there was a history of old standing biliary colic, and the presence of gall stones is said to have a marked effect on the production of cancer and chronic inflammatory affections in this region. Both of these patients died a few months afterwards.

A young unmarried woman, aged 22 years, gave a history of attacks of colicky pain in the epigastrium for the last eight or nine years. These attacks lasted for one and a half to three hours, and came at intervals of from two to six weeks. The pain was felt radiating out from the epigastrium. She was never jaundiced. The attacks so far as she knew bore no relation to her meals or to food taken. On the day following the attack practically all symptoms of it had vanished. On opening the gall bladder I found the fundus about twice the normal size, elongated and sagging downward. The bile was thick and treacley; the cystic duct was dilated in its upper part. A No. 4 sound could be passed. No gall stones were present. Part of the fundus was cut off and the raw edge was attached to the abdominal wall. I judged that by shortening and straightening the gall bladder, the bile could the more easily escape, as the thickened condition was probably due to stasis. Since then, five months ago, the patient has been quite well. This case showed a fair amount of intermittency, but the symptoms of the case I am about to mention were of a fairly mild, but persistent character. He was a man sixteen stone in weight and 33 years of age. For the past six months he had been troubled with more or less pain in the region of the gall bladder, and for the last six weeks he had been jaundiced; the jaundice gradually increasing in degree. He had, I learned, a slight and varying temperature all through, and for a short period before operation it had ranged as high as 102°. His gall bladder held about half a pint of thick bile, which was not purulent. There were no gall stones, and only a few adhesions about the neck of the gall bladder. The gall bladder was drained and the temperature and jaundice subsided. He left hospital in two months time quite well. A few weeks after this he became ill with a profuse and frequent diarrhoea, and in the interval preceding this he complained greatly of his want of appetite and his weakness. I saw him a few hours before death, I could discover neither sign nor symptom of liver trouble. No post mortem could be obtained, but I was very much inclined to think that both illnesses originated in some intestinal condition of a septic character.

I hope I do not assume too much when I say that there is a common impression held by many that the intense pain of biliary colic is due to the effort on the part of the biliary passages to expel gall stones. This is, probably, in the great majority of cases, a totally erroneous view, and most likely the correct one is that each of the attacks represents an attack of cholecystitis. Owing to the inflamed condition of the mucous membrane of the gall bladder, and particularly the bile passages, there is a resistance to the outflow of the bile and mucoid secretion. The increase in tension thus occasioned immediately excites within the tender gall bladder a reflex spasm, a biliary colic.

Spasm of the urinary bladder will take place when ulcer or acute cystitis is present. Attacks of renal colic are not uncommon in cases where the stone does not engage the ureter. A man may have stone in the kidney for years without giving rise to any pain whatever. How often, on the other hand, has a kidney been cut down upon for spasmodic colicky attacks, a marked symptom of stone when no stone has been present. We can only infer then that these attacks of pain are due not necessarily to a blocking obstruction, but to a reflex spasm, brought on by perhaps an amount of interference sufficient to produce but a slight increase in the pressure on the irritated epithelial surface behind it.

The very fact that, in some, biliary colic has been present in a marked degree when no gall stones have been present, is sufficient to induce one to believe that other conditions besides gall stones must bear a causal relation to the colic. This may be due to inspissated bile and to pressure from without, but considering the number of cases in which varying degrees of an ulcerative process have been found, there is a strong presumptive evidence that pathological changes in the mucous membrane or the wall of the gall bladder are a very strong factor in the production of biliary colic.

Naunyn and Stolz state that the bile is not absolutely aseptic, but that organisms and usually bacillus coli, are few in number, very attenuated and only obtained by sowing the culture medium with large quantities of biliary fluid. If streptococci are carefully introduced into a normal gall bladder they are got rid of fairly quickly, but if the mucous membrane is injured, or if the outflow of bile is obstructed, the organisms present multiply and probably a fresh invasion takes place, for bacillus coli almost always predominates.

Attacks of biliary colic, of cholecystitis, or of

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.

The

Let us look at the pros and cons of surgical versus medical treatment. Gall stones are almost always formed in the gall bladder. 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 sequela 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