I have seen in my own patients in helpless cases. If I lived a little while and was comfortable from it, it was better than so much pain.

I will say that I have had no pain since the twentyfirst day of last October, the day of the operation, no pain from this trouble. I have had to use the catheter frequently or rather I have had no occasion to use the catheter since except for irrigation.

I wish to say more than that, that the objections Dr. Smith has referred to as to incontinence of urine, I have never recovered control of yet, and I don't know as I ever shall. I shall still be thankful to the members of the profession who have developed this method, and are practicing it. I shall still be thankful that I submitted to the operation if I never obtain control of the urine. It is a thonsandfold better to be obliged to resort to the use of the urinal than it is to be obliged to resort to the use of the catheter constantly, and so far as the pain is concerned, it is nothing. I had rather be obliged to use the urinal all the time, than to use a catheter. I have had to use it, and suffer the pain that we do in these At that time this operation was performed upon me in Hartford, I think I may say that according to my best knowledge it has been performed as many times in this state and in Hartford perhaps as many, as any other part of the state and more than it has in the city of Boston. And the very person to whom I went three years ago last November and who refused to entertain the idea of performing any operation on me, the same men are performing operations successfully to-day and doing it frequently, and it is being done all over the country. Until 1898 it was difficult for me to find anybody who would entertain the thought, and for months, while I was very anxious to have the operation performed upon me, there were but few surgeons that were willing to undertake it. I stand as a witness to bear my testimony to the good results of this operation. (Prolonged applause.)

THREE CASES OF OBSTRUCTION OF THE CYSTIC

DUCT SIMULATING APPENDICITIS.

GEORGE R. HARRIS, M. D.,

NORWICH.

At the present time, diseases of the gall-bladder, including gall-stones, are causing as much or more interest than appendicitis; and many symptoms, which in years gone by, have been attributed to other diseases are now recognized as evidences of disease of this organ.

The more we study our own cases and the more we read the reports of the experiences of others, the more we are brought to realize the strong resemblance between affections of the gall-bladder and some other diseases, especially appendicitis, and the more uncertain becomes the diagnosis between these conditions.

In fact, some authorities go further and claim that they are usually both present, and that the conditions which favor an attack of appendicitis are identical with those preceding an attack of gall-stone colic.

This term, gall-stone colic, is a misnomer, as it is now pretty generally admitted that all the symptoms supposed to accompany an attack of gall-stone colic may be present, and on examination find no gall-stone. The terms hepatic colic or biliary colic, or gall-bladder colic would be more appropriate.

Concerning symptoms of appendicitis nothing will be said, as the subject is one which has been thoroughly and frequently gone over.

This will naturally lead us to a brief consideration of the diagnosis of what is commonly called hepatic colic.

What is the cause of hepatic colic? It is usually due to obstruction of either the common or cystic duct, with an accumulation of bile behind the obstruction, which

result in distention of the gall-bladder. Now this obstruction may be caused by gall-stones, thickened bile, bends or twists in the duct, from old adhesions, congestion of the membrane lining the duct, or by pressure from outside bodies, as glands, etc.

Regarding the formation of gall-stones there are two theories. One, that there is a chemical change in the bile which causes precipitation of its solid constituents. The second, that the infection of the gall-bladder with the colon bacillus, or the germ of typhoid fever, gives rise to cholecystitis and the secondary formation of stone. Thickened bile may occur in cholecystitis, especially in cases where old inflammatory changes remain, which cause bending or twisting of the gall-bladder or ducts. Congestion of mucous membrane also occurs in cases of cholecystitis.

In speaking of diagnosis, I will reprint Haggard's quotation of Ochsner, which appears in "The International Journal of Surgery" of February, 1904, which reads as follows:

"The symptoms which will most constantly lead to a correct diagnosis when gall-stones are present are not biliary colic, jaundice and passing of gall-stones with the feces, as we have been taught for many years, but (1) digestive disturbances, a feeling of weight or burning in the vicinity of the stomach after eating, gaseous distention of the abdomen; (2) a dull pain extending to the right from the epigastric region around the right side about at a level with the tenth rib, extending to a point near the spine and progressing upward under the right shoulder-blade; (3) a point of tenderness on pressure between the ninth costal cartilage on the right side and the umbilicus; (4) a history of having had one or more attacks of appendicitis or typhoid fever; (5) in many of these cases there is a slight tinge of yellow in the skin, not sufficient to be recognized as icterus, but still sufficient to be perceptible upon close inspection, especi

ally on the days on which the patient is not feeling very well, when she complains of feeling bilious; (6) there is usually an increase in the area of liver dulness; (7) there may be a swelling of variable size opposite the end of the ninth rib."

The increased sensitiveness over the gall-bladder is a very valuable sign.. Many times you can outline the gall-bladder, especially when the liver is forced downward by a deep inspiration. These symptoms, followed by the acute attack of colice with its pain in the epigastrium, and sometimes radiating, nausea and vomiting, abdominal tenderness most marked over the gall-bladder, with rigidity of the right rectus muscle, and occasional jaundice, are what we must rely on in making our diag nosis in favor of the gall-bladder.

Although it does seem as if a diagnosis between hepatic colic and appendicitis was an easy one to make, nevertheless, there are cases where it is very difficult, and I have operated on three cases, in one of which the diagnosis was not made until after the incision, and the other two, only after the patients were thoroughly anesthetized.

On July twenty-sixth, 1897, Mrs. B., a widow, aged seventy-six, American, called me and stated that although usually in good health and a hearty eater, on the day before my call, she had been taken sick with what she called an attack of indigestion and was confined to her bed.

She had vomited profusely, had marked tenderness in the epigastric region. I diagnosed the case as gastro enteritis and gave usual remedies. Did not see her the next day, but on the twenty-eighth was again called and found that she had grown much worse, after a slight improvement lasting several hours. Her vomiting had grown more frequent and she now had considerable diarrhea, with much more pain than when I first saw her and the pain was to the right of the median line in

the neighborhood of McBurney's Point. Had temperature of 99 12 and pulse 100. Right rectus muscle very rigid; percussion on right side gave dullness most marked in vicinity of McBurney's Point. She had considerable distention of abdomen and appeared very sick.

This woman was carried into the Hospital and seen by several men, at a consultation called for that purpose, and declared by everyone to be a case of appendicitis. She was etherized, the abdomen opened and a normal appendix brought out and removed. Further examination revealed a smooth, elongated body, about six inches in length and about two and one-half inches in diameter, presenting at the upper angle of the wound; this was easily recognized as the gall-bladder. Its wall was very firm and tense and there were no adhesions to surrounding parts. The opening was enlarged; it was brought out through the wound, thoroughly walled off from the abdominal cavity with gauze, opened and emptied, an artery clamp retaining the bladder in position and preventing its returning into the abdominal cavity. The contents seemed to be bile which was not much changed in appearance from normal bile.

A scoop now brought out two fairly large stones with rough surfaces and with facets. These were in the portion of the bladder nearest the neck and required some little maneuvering to release them. The duct was not thoroughly examined and no other enlargements were found. I now packed the gall-bladder full of gauze to absorb the bile which was flowing quite freely, and stitched the bladder to the upper end of the abdominal wound and then closed the rest of the wound. Suitable dressing was applied and the patient was removed to the ward where she made an interrupted recovery, the sinus remaining open and discharging more or less for six months. She has since had no trouble.

Now this case gave no history of previous stomach affections and on my first visit was to all intents and