In making drainage in these cases, it is much more preferable to stitch the bladder to the peritoneum only, rather than to the facia, or even skin, as practiced by some. The advantage of this can be seen when we realize that in drawing the bladder to the outer surface we make a fistula with mucous membrane throughout, and in case the common duct becomes patent, or the condition in the bladder entirely subsides, we find that it is with much more difficulty that we are enabled to get such a fistula to close than would occur if the bladder is sewed to the peritoneum only. Absorbable suture only should be used in doing such work, as it is possible, and rather probable, that an unabsorbed suture would find its way into the bladder, and would make a most excellent nucleus for the reproduction of stones. Catgut is the ideal suture in these cases, and drainage by rubber tubing.

I wish to call attention especially to the point of attaching the bladder as high up as possible so that in case of prolonged drainge the bladder may be at the desired time in a position to succulate, instead of having the fistula low down, in which case the bile runs out continuously, simply from the position it occupies, and may keep the fistulous condition present for an indefinite length of time. The following brief report of cases is more to show the variety of condition which may be found in these cases, and in the majority of which it is impossible to tell the condition present until the abdomen is opened, and then it is with our eyes and our fingers we can decide the best procedure to take :

CASE I.

Miss O., age thirty-four, history of repeated gall stone colic for eight years, without jaundice. During six months previous to operation was never free from pain. She had localized tenderness over region of gall bladder. Cholycystostomy done. Bladder found to be very small, about the size of an English walnut, and with its wall about one-fourth inch in thickness. The bladder contained one large stone, and one other was teased from the cystic duct, and removed. Rubber tube drain was inserted, and removed on fourth day. Patient made a good recovery, leaving hospital four weeks later.

CASE II.-Miss H., forty years old. History of having gall bladder attacks for eight years. Was in septic condition, running temperature all the time. Gall bladder opened and found distorted and completely filled with a material of the consistency of partially-dried putty. Cholycystostomy done, with complete recovery after three or four weeks.

CASE III. Mrs. G., thirty five years of age. History typical of gall stones for several years. Gall bladder exposed, and found to contain no stones. Adhesions about bladder freed and abdomen closed. Recovery complete, and has had no return.

CASE IV.—Mr. M., age forty-two. Gall bladder disease, following attack of typhoid fever. Bladder opened, condition of empyema found. Sixty-odd stones removed. Has since been jaundiced from time to time, and has passed a number of stones through fistula.

The last three cases reported were seen by me during my association with Dr. Ap Morgan Vance.

Society Proceedings.

PROCEEDINGS OF THE LOUISVILLE CLINICAL SOCIETY,
MARCH 7, 1905.

DR. W. H. WATHEN: Case I.—I will report a case of extra-uterine pregnancy of about four months, operated upon last Wednesday. The fœtus was probably dead sometime before it was removed, but its appearance would indicate a development of about four months. The placenta and the cord are also here. Both tubes and ovaries were removed. The pregnancy developed in the outer part of the tube, probably in or near the ampulla, and when the operation was performed the placenta was attached to all parts of Douglas' pouch, to the posterior part of the uterus, and also to the broad ligaments and tube upon the left side, obstructing the outlet to the mouth of the tube, as will be seen from this specimen. The foetal membrane can, however, be separated by dissection from the outer end of this tube. It was also adherent to the appendiculo-ovarian ligament, and when separated left a long bleeding surface upon the under side and border of this ligament.

The history of this case is peculiar. It was Dr. Morris' case, and he called Dr. Bailey and myself in consultation. There seemed to have been no well-marked symptoms of pregnancy up to the time I saw her. She had no nausea, no vomiting, no enlargement of the breasts, and her menstruation had been regular. She had borne several children previously, but none, I believe, for a few years. About a month before I was called to see her she had her menstrual period, and I learned from Dr. Morris that she had considerable pain at that time and a rapid pulse. This all passed away without suspecting pregnancy until about ten days ago, when she began to suffer severely, and her heart became very rapid, beating 160 times a minute, and her pulse was irregular and intermittent. Dr. Morris and Dr. Bailey administered the proper remedies and called me, and I could get no symptoms from her that indicated pregnancy. In the examination I felt in Douglas' pouch a mass that I remarked felt like placental tissue, but as there was no history of pregnancy that far I could not imagine how that could be.

In the operation I found just what I have shown you. Further, this woman had a mitral regurgitant murmur, pulse beating still irregularly and intermittently; but just before the operation, at Norton Infirmary, the pulse became regular and came down to 120. There was nothing unusual in the operation, no shock following it, and the woman was returned to bed in good condition. She was operated on last Wednesday; on Friday morning her pulse was 108, and she was doing well. At half-past one I was called, and found her pulse 160. The nurse's record showed

that thirty minutes prior to this the pulse was 108; the pulse was not of good volume; there was no hemorrhage, because the woman had no disturbances of vision; the pupils responded promptly; no coldness of the body; no cold, clammy perspiration, and none of the evidences of internal hemorrhage except the rapid pulse. Her pulse never came lower than 125 after that. She passed gas freely until about ten hours before her death, and was flat until that time. She was perfectly conscious until a few hours before her death. Her temperature went up on Friday afternoon, about fifty hours after the operation, to 104, abdomen still flat, gas passing freely. Her pulse was of much better volume, but never got under 125. On Sunday morning, the fourth day, she was somewhat distended in the epigastric region, her pulse grew rapid, and she gradually faded away and died, passing no gas the last ten hours of her life.

What caused this sudden shock I am unable to say, but the last day would indicate there was some kind of sepsis. Now, her uterus was three times as large as normal, and after the operation a mass as large as my two fingers came from the uterus, which looked very much like the beginning formation of a placenta; it was possibly thicked decidual membrane.

Now, whether this woman had sepsis from something within the pelvis, or whether some sepsis developed in the uterus, I do not know, but there certainly could have been no extensive peritonitis, and the infection. must have been more of a systemic infection than of a peritoneal infection.

There is one point that I want to bring out here; used catgut in ligating the pedicles, which were very think and broad. Is it possible that this catgut could have had anything to do with it? About eight years ago I removed from a uterus a large myoma by excision, and I used catgut to unite the cut edges; the patient died without any peritonitis, and was feeling just as this patient did-perfectly well-with a temperature of 104-5 and a pulse of 140-150. She felt well until she died. This woman claimed to be better all the time until she became unconscious. Might it not be possible that the infection was received from the catgut in this case?

Case II. This tumor was removed this afternoon from Dr. Morris' patient. It is an irregular fibroid tumor of the uterus, and upon one side is the remains of an intra-ligamentary cyst. The appendix was removed; it was lying down in the pelvis, and when the adhesions were separated it was left in a rather crippled condition. It was not removed because of any diseased condition within the appendix, but because there was a raw surface over two-thirds of the appendix from the separation of adhesions, and it would probably become adherent and cause trouble. I do not believe in removing healthy appendices at all, but when we have an apèndix with the peritoneal covering injured, and we have a raw surface from the separation of adhesions, it is better to remove it, because it may become

adherent afterwards and require removal. It adds nothing to the danger of the operation.

Case III.-In conclusion, just a few words about another case. Yesterday I operated at Greenville, Ky., on a woman who for two months felt a tumor in the abdomen below the umbilicus. When I examined her I found what was apparently a tumor within the abdominal cavity almost as large as a man's head. The woman was brought over to the side of the bed, and without anesthesia an incision made into this tumor, and over a half-gallon of pus came away. When the pus was all discharged, upon examination with the finger and a probe I could find no connection with any tumor within the abdominal cavity; apparently all of this mass was lying within the abdominal wall itself. Before operation in the vaginal examination the tumor pressed down upon the womb, and by percussion you could find apparently a large cystic tumor within the abdominal cavity. This is peculiar in that what apparently seemed an extra-abdominal tumor was merely a tumor of the abdominal wall, and peculiar in the fact that I am unable to arrive at any conclusion as to the probable cause of this tumor. The waman had no fever and no increase

in the pulse rate.

DR. FLEXNER: What was the previous history?

DR. W. H. WATHEN: There was no history except that about two months ago this tumor began to form.

DR. IRWIN: These cases are of extreme interest, especially the last one the essayist reports-the one with abscess of the abdominal parietes. I have met with several cases of abscess of the abdominal wall, but none of them was as large as the one the Doctor has reported. I saw, about two years ago, a young woman less than twenty-five years of age who had met with an injury of a peculiar kind. On Sunday morning she and her sister were preparing to go to church, and they quarreled over the clothes they should wear. One sister got the other down, and when she did so she jumped on her abdomen with French-heeled shoes. The abscess formed somewhere in the abdominal cavity, and in a short time discharged into the intestinal canal. Pus discharged freely from the bowels and through the vagina. There were no local signs of an abscess in the abdominal walls, but the patient died. I suggested an operation, but this was not agreed to, because the family did not want to expose the history of the case. This was the most remarkable case of the kind I have ever seen. I do not know whether the pus formed within the abdominal walls or within the intestines. She lived two or three weeks, and must have discharged three or four pints of pus in this way.

It

DR. BAILEY: I have nothing of value that I can add to this case. was of great interest to me, and before I saw the case at all Dr. Morris had administered remedies for the shock. In the early morning she had taken position on the commode for evacuation of the bowels, and possibly

the rupture occurred at that time from straining to evacuate the bowel. The case is interesting to me because she had given no signs of pregnancy. She gave a history of menstruating every twenty-eight days, and she said that the discharge twenty-eight days before this time had. not been normal; there was some of this discharge that passed in the last days of this illness such as Dr. Wathen saw in making a vaginal examination. The heart was a bad one; the elimination by the kidney seemed to be fairly good. She took the anaesthetic beautifully, and had no nausea afterwards at all. We thought ourselves extremely fortunate that we had no complication in connection with the anaesthetic. The patient apparently for some two days did perfectly well, and, so far as I can see later on, the death was not due or had any connection with the parts that were operated on. My judgment was that death was due to sepsis coming from the uterus. I do not know how it was caused. It might have existed before that time, and yet there was no fever and no discharge up to the time of the operation; but the uterus was much enlarged. I did not see the discharge that Dr. Wathen describes, but no doubt it was a development of membrane in the uterus that came away; this is not unusual in connection with extra-uterine gestation. The uterus was much enlarged, and there was the formation of a membrane of some character inside of the uterus, and it seems to me that it is easier to account for the death of the patient from the condition of the uterus that from the catgut ligatures.

DR. W. H. WATHEN (closing): One point, the uterus was dilated large enough to introduce your finger, and the character of tissue that came away was entirely different from what we ordinarily see in ectopic gestation. There we have shreds of mucous membrane, but here there was a solid mass over a quarter of an inch in thickness and three inches long and an inch and a half wide. May it not have been that this womb conceived also, and the conception died, and this was the remains of the beginning formation of a placenta? We have quite a number of cases reported of conception, both in the womb and out of the womb at the same time.

DR. WILLMOTH: Did you have the catgut examined that you used in the abdomen?

DR. W. H. WATHEN: I have no more. It was boiled before using.

PROCEEDINGS OF THE LOUISVILLE SOCIETY OF MEDICINE AND SURGERY, FEBRUARY 20, 1905.

DR. VANCE: I have a specimen of an appendix that presents two or three points of interest. About the middle of January, I was called to a young Englishman of twenty-seven about 12 o'clock at night. He gave the history of having had only a slight "stomach ache" at 2 o'clock in