At the apex of the gall bladder and filling the cystic duct we find the stones. No jaundice in these cases, nor disease of the common duct. Another class of cases: I have had several cases within the past month that were more or less jaundiced and gave history of repeated attacks of pain in the region of the gall bladder, some of them extending over a considerable period; the jaundice becoming less intense at times but not entirely disappearing from the sclera, nor the bile from the urine. In this class of cases I have invariably found the gall bladder situated high up, far under the liver and very small, closely hugging the stones, containing practically no contents fluid in character. Often in these cases we note dense adhesions of the omentum, which require separation before the gall bladder can be reached and isolated. After removal of the stones we are unable to pass a probe through the common duct into the duodenum, it being completely obstructed as a result of inflammation probably from the duodenum, streptococcic and colon bacillic invasion. A point worthy of special interest in these cases is the marked diminution in the plasticity of the blood, rendering its coagulability tardy, oftentimes alarmingly slow. No bleeding point, however small, should escape a ligature, and the entire raw surface should be relieved of further oozing by a carefully but firmly arranged sterilized gauze pack. Do not disturb this safeguard for at least ninety-six hours, probably longer still, unless the local or general symptoms warrant its removal, and in that event be prepared for a speedy repacking, for an alarming and rapidly fatal hemorrhage might attend the removal of the primary pack. Another class of cases: I have just dismissed two such cases-empyema of the gall bladder, both occurring in ladies under thirty years of age. In one case a stone was found obstructing the cystic duct, the gall bladder being distended; the patient was not jaundiced but was sallow and septic. Gave history of fever for some time, not unlike a malarial remittent in many respects. I will state that empyema of the gall bladder is the only disease that is strikingly similar, clinically speaking, to a malarial remittent (the plasmodia settle the malarial feature), and if the organ be palpable diagnosis can be readily made. The other case of empyema was a suppurative cholecystitis with obliteration of the cystic duct. This gall bladder was removed. The first case was stitched to the abdominal wall, (cholecystostomy) and drained, and I now believe that she would have made a more prompt recovery had cholecystectomy been done. Another class of cases, and I am done, as their relation concludes my limited experience in gall bladder surgery. The gall bladder was removed in four cases-one for suppuration, the remainder for catarrhal obstruction and productive inflammation due to an infection that destroyed the functioning portion of the organ, but not pus-producing. I regard the removal of such bladders as essential to the patient's safety, as in them is situated the main focus of infection, and this germ, like many of its fellows, possesses the power of penetration. They escape from their imprisonment in the gall bladder into the liver substance, and there bring about necrotic changes (Eisendrath) impairing the function of the liver and finally if not relieved terminate in death. The importance of gall stones has by some of the profession long been recognized, but additional evidence was produced by Halstead. At the June meeting of the American Medical Association, in a paper read by Dr. Bloodgood upon the subject of hemorrhagic pancreatitis, he reported a case of this kind, and post mortem found a stone in the diverticulum of Vata, which produced complete pancreatic obstruction in addition to biliary. Section of the pancreas showed extensive extravasation of blood throughout the organ, the function of which seems so imperfectly understood. This paper is intended merely as a clinical résumé of my recent experience, hence but little time will be devoted to the etiology, pathology and symptomatology of affections of the biliary apparatus. That the formation of gall stones is secondary to an infection of the common duct primarily, and later the cystic and gall bladder, is pretty generally conceded. That women are much more frequently the subject of this form of trouble is a fact everywhere recognized. Likewise they suffer from duodenal disturbance and consequent improper drainage due to irregular and indiscreet eating and lack of physical exercise-a prominent factor in laying a foundation at least of biliary and hepatic disturbances. For the symptoms as observed by myself you are referred to the May issue of the MEMPHIS MEDICAL MONTHLY containing my article on this sub- ject. Regarding treatment I have but little to add to my former article in the management of that class of cases where the gall bladder is distended but practically free from pathological lesions. Generally we find here one or more stones lodged in the cystic duct. The proper procedure under such circumstances would be to aspirate, incise the fundus, remove the obstruction, close the incision by a row of sutures inserted through all the coats with fine silk and then sero-serous sutures overlapping the original line of sutures. The organ is dropped back into the cavity, and in ten days your patient is able to leave the hospital. With reference to the second class of cases, where the gall bladder is diseased somewhat, with at times pus present, it was formerly my custom to do a cholecystostomy when long time was required to effect closure, and then we had the gall bladder anchored, which necessarily interfered with the normal mobility of the liver. I now regard these cases as suitable for cholecystectomy and remove the gall bladder entirely just as I do in those cases of productive inflammation of the gall bladder, where the liver is subsequently invaded by the microöganisms setting up necrotic changes. It not only simplifies the treatment very much, shortens convalescence and gets rid of an organ that in health is of questionable use only, rendered totally worthless by disease and a source of danger and a menace to its owner. Occasionally cases come up presenting insurmountable difficulties. They are not suited to closure neither can their removal be effected. Here we have to drain, and the operator will select that method best adapted for the safety of the case in hand. Porter Building. Discussion. Dr. O. S. McCown, Memphis: The subject of gall stones is one of interest to the general practitioner as well as the surgeon. In my practice I recently had a case in which, being positive of the diagnosis, Dr. W. B. Rogers was called in to operate. A stone was found in the duct, but while the gall bladder was full of bile, there were no stones in the viscus. The patient was relieved until about six months later, when she was again attacked with symptoms of gall stones, and later passed several laige stones. I would like to know if these were newly formed. Dr. John L. Jelks, Memphis: I would like to ask Dr. Smythe if he anchors the gauze in the gall bladder in his operations or not? Dr. William Britt Burns, Memphis: I have had the pleasure of seeing several cases of gall stones with Dr. Smythe. It has been shown that a greater percentage of cases of heart disease have gall stones than do those without. Where ox gall is given 23 per cent. of fat is lost in these cases, but where it is not given 60 per cent. of fat is lost, making me therefore think that its administration is good practice in addition to surgical measures. Pancreatis is a disease of which little is known. Obstruction of the pancreatic duct by ligature will produce fat necrosis; hemorrhagic spots are also found in those cases in which fat necrosis exists. In acute pancreatis the spleen is atrophied, showing that there must exist some relationship between these organs. Dr. Jere L. Crook, Jackson, Tenn.: We are indebted to Dr. Smythe for bringing forth such an interesting subject. I would like to know the number of stones he found in his cases, having seen a case in which 140 were counted, but stopped at that number as we became tired. Dr. Smythe, closing: With considerable experience I have not found stones in the hepatic duct, but I have no doubt that they exist. To Dr. Jelks I will say I hardly recognize the condition as necessitating the anchoring of gauze in the gall bladder, but follow the method already laid down. In reply to Dr. Crook, I have never counted the number of stones in my cases, but the sister at the hospital informed me that in one of my cases she had counted 208 stones. The diminished plasticity of the blood is necessarily a point of great interest, as the patient may bleed to death if ligature of vessels is not practiced. REPORT OF TWO CASES OF OVARIAN CYST.* BOLIVAR, TENN. IN presenting the following cases of ovarian cyst, it is not my intention to attempt to advance any new ideas, but to illustrate that by observing the principles of modern surgery, laparotomies may be performed successfully in the country under circumstances that seem most unfavorable. It is well for the general practitioner in the country to be * Read before Tri-State Med. Assn. (Miss. Ark. & Tenn.) Memphis, Nov. 19, 1901 on the lookout for almost any abdominal tumor, and to be able to diagnose large cysts from ascites, peritonitis or pregnancy-especially the latter condition; for cysts occur in the married as well as in the unmarried, and usually in young women. Suspicion of pregnancy is cast upon any young woman with an enlargement in the abdomen, and often the physician will relieve great anxiety among friends, and also save his own reputation, by giving a positive opinion whether the case is one of pregnancy or a pathological enlargement. The history of the function of menstruation in these two cases is as contrary as any two histories could be, one suffering from amenorrhea with but few symptoms, the other from a most distressing dysmenorrhea. The differential diagnosis between ovarian cysts and other tumors in the abdomen is sufficiently described in all textbooks on gynecology, so I will not dwell upon it, but I think the signs of a large cyst are brought out clearly enough in these cases to make the diagnosis easy. Case I. Mrs. S. M., white, 29 years of age. Family history negative. Personal history: married; commenced menstruating at the age of 14, and menstruated again in six months, but not again until May, 1900, and March, 1901. At the time menstruation was expected she had some pain in her back and hips, also some leucorrhea. The menstrual flow was very slight, lasting only one day at most. She had been married thirteen years, but had never become pregnant. Her general health was always poor. There was dyspepsia, her bowels were constipated, and she suffered a great deal with headache, which did not come on with any regularity. She first noticed the abdomen more prominent about two years ago, and suspecting pregnancy her health seemed to improve. She could not remember upon which side the swelling began. After increasing in size for one year the abdomen remained about the same for several months, and it then began to increase more rapidly. Her general health again began to fail, and she would have repeated attacks of colic, which were not accompanied by vomiting, fever or abdominal tenderness, which excluded localized peritonitis; she also suffered with heartburn, fainting spells, shortness of breath and strangury. She had not been able to perform any of her household duties for twelve weeks, remaining most of the time in bed, resting in |