and the vomited matter became offensive. Recognizing a progressive but as yet incomplete intestinal obstruction, operation was proposed and accepted. Vague right iliac resistance was made out with difficulty on account of abdominal distention and rigidity, but became plainer under the influence of the anaesthetic. Incision as if for appendicitis disclosed great distention and congestion of the small intestine, with adhesions about a tumor in the right iliac region and considerable free fluid in the abdominal cavity. Loosening the adhesions, which were of recent lymph, an object could be felt within the ileum, and the intestine below or distal from this object was collapsed. The object was extracted through a longitudinal incision in the gut (afterwards closed by suture), and proved to be a gall-stone cubical in shape and completely occluding the lumen of the intestine. The size and shape of the stone were found to be about the same as those of a partly-used piece of billiard chalk. It could not have passed through the gall-ducts, and how it got into the intestine by ulceration without greater constitutional disturbance I am at a loss to imagine. The patient made an excellent recovery.

It is my belief that the time is not far distant when the removal of the gall-bladder without inflammatory disease, but merely to get rid of gall-stones and their dangers, will be of common occurrence. This opinion is strengthened by the ease and safety with which I accomplished this in the following case.

CASE X.-Jette S., twenty-nine years old, came to the hospital with a diagnosis of gall-stones and consequent frequent colic, some of the stones having been found at various times in the stools. There had never been symptoms of inflammation, the pains usually subsiding suddenly and completely. The colic was so frequent and severe, however, that the patient gladly consented to operation. The ducts were explored and the viscus readily removed by the method already described, the raw liver surface being covered by peritoneal flaps. There was some suppuration at the stump of the cystic duct, but recovery was otherwise unimpeded. The unopened gall-bladder is still in my possession.

The histories which have been given in this paper are, with one exception, selected from those of patients whom I have operated upon during the past year. Two cases which terminated fatally must also be mentioned here, since they teach by contrast.

CASE XI. The first of these patients was a woman, forty years

old, who had for years suffered from recurring attacks of cholecystitis with jaundice. I operated upon her in deep jaundice on April 3, 1900, and she died of hemorrhage. A small vein in the region of the common duct was shown post mortem to have been the principal though not the sole cause of the bleeding. It was recognized at the time of operation that steady but not alarming hemorrhage was going on, and packings which under ordinary circumstances would have been sufficient were carefully put in. Death came within twenty-four hours.

CASE XII. The other patient was also a woman, septic and much run down on account of common-duct obstruction. Here, too, there was deep jaundice. The progress of the case made it evident that without operation life could not be much prolonged. This patient died within forty-eight hours from shock.

With the exception of cases of malignant disease these are the only deaths which have occurred during the year, and they might have been avoided by more timely intervention.

In conclusion, let me call your attention to the fact that, as in so many other grave abdominal diseases, the disorders of the gallbladder and ducts respond to surgical treatment in direct proportion to the timeliness of the operation. For reasons which I am absolutely unable to comprehend, the average practitioner of general medicine waits longer in gall-bladder disease before he calls the surgeon than he does in any other grave abdominal lesion. The results of operation, with but rare exceptions, are to be studied with this point in view. If the percentage of cures be high, it is so in spite of the most adverse circumstances, and if the cures be few and the death-rate high, we must remember that most of the patients who submitted to operation did so as a last resort, when the disease itself immediately threatened life and the vital forces had been sapped and undermined by long-continued sepsis and the disturbances incident to chronic icterus.