The dangers of leaving these tumors alone are hemorrhage, depletion, sepsis, and death. Another indication for operation is rapid growth; should any myoma become very rapid in its growth we have reason to believe that transformation into sarcoma is taking place.

Dr. Broun: In answer to the doctor's question; fortunately we found that the results of removing fibroid tumors which had undergone sarcomatous change were very good; we do not know that the sarcoma is present until after the miscropic examination. In some instances there has been recurrence at a late date of three or four years, but that is uncommon; in the majority of instances there has been no recurrence in that particular spot. In one instance there was a recurrence in the scar itself. Concerning the real objection, the most important objection to operating through the vagina, is the possibility of future intestinal trouble. Kolme reported two cases of his cwn, and five or six that he had collected, in which varying from two months to two years intestinal obstruction took place and sometimes death as a result of coils of intestine becoming detached through the vaginal incision. In my own persona! experience I have had two patients, one that died a year afterwards in St. Luke's Hospital, another that died six months afterward in a distant portion of the country, both as the result of coils of intestines becoming attached to the vaginal scar. Such unhappy results makes me believe that I do not care to go through the vagina.

THE PRESENT STATUS OF GALL-BLADDER
SURGERY.

BY ROBERT NEWTON PITTS, M. D., OF MONTGOMERY. Junior Counsellor of The Medical Association of the State of Alabama.

During the past quarter of a century surgery of the gallbladder and its ducts has been perfected to a marked degree. Great credit is due to American surgeons for their original work in this field; in all text books on gall-bladder surgery, both foreign and American, the names of Murphy, Sims, McBerney, Mayo, Ochsner, Bobbs, Richardson, Halstead, Finger and others, are prominent on many pages.

Gall-stones are formed chiefly of cholesterin and bilirubincalcium. There are also traces of magnesia, bile acids, fatty acids, copper and iron. The nucleus consists of bacteria and altered epithelial cells. The number of stones range from one to several thousand. They are shaped according to their place of lodgment. When found in the ducts, they are oval, spherical and cylindrical. If many accumulate in the bladder, attrition produces factes, giving them polyhedral shapes. As to the etiology, age plays an important part, gallistones being most frequently found in patients of middle age or advanced in years. Naunyn found gall stones in one in thirty cases under thirty years of age; one in six after sixty years of age. Two-thirds of all cases occur in women. Osler claims that 40 per cent. of all women over forty years of age carry gallstones. Galippe was the first to advance the idea that bacteria caused gall-stones. Soon after, Welch and Hunner arrived at the same conclusion. Cushing took issue as to the microbial origin. Csler also raised the question whether in.... fection produced the stones, or whether the stones rendered the gall-bladder a fertile field for germ production. Gilbert and Mignot were the first to produce stones in rabbits by artificial means. Mignot in his work says that aseptic foreign bodies will remain in the gall-bladder an indefinite period without causing inflammation or precipitation of the bile salts. Gilbert produced stones by artificial means, in a rabbit by injecting into

the gall-bladder attenuated typhoid bacilli. Six weeks after he removed the stones and made pure cultures from them.

The bacillus coli communis, bacillus typhosi, streptococcuspyogenes and staphlococcus aureus are the stone producing germs.

Bacteria infect the gall-bladder in one of two ways; first, from the duodenum through the common duct; secondly, through the circulation, chiefly the portal vein. The physiologists tell us that cholesterin is sparingly found in the blood, and not at all in the liver except in abnormal conditions, yet being the constant constituent of the bile, it can only be accounted for chiefly, if not wholly, as a product of the epithelial cells that line the gall-bladder. Such being the case, any discase of the cells will produce a precipitation of colesterin and lime salts.

I will not tax your patience by attempting to give you a full description of the pathological lesions that are found in cholecystitis and other conditions of the gall-bladder. If bacteria of a virulent type are injected into the gall-bladder of a rabbit, gall-stones will not form. But if, on the other hand, an attenuated culture is injected, there will follow a desquammation of the epithelial cells, which in combination with the bacteria go to form the nucleus for the stones. After a time. the inflammatory condition affects the bladder walls; these become thickened from the inflammatory deposits. Localized peritonitis also take place. The plastic material thrown out causes an adherence to all of the adjacent structures. After a time the fibrous bands begin to contract which causes a shrinkage of the bladder. At times it will degenerate into a small fibrous mass, changing the bladder so that it is hardly recognizable. The same pathological conditions can be said of the common duct. It also thickens and adheres to all of the surrounding tissues. Ulceration will, oft-times, infect the gencral cavity, before nature can throw out sufficient plastic material to wall against general peritonitis. Ulceration of the duct is productive of stricture formation. The inflammation may extend from the common duct upward into the hepatic ducts, from thence into the hepatic cells, thus causing the liver cells, by this inflammatory process, to be replaced by fibrous tissue. Klebbs was the first to call attention to malignancy of the gall-bladder following gall-stones. This fact is caused by constant irritation. Moynihan reports 84 cases of malignancy of the gall-bladder; 74 of these cases contained calculi, Musser

and others sustain the position that gall-stones are a productive source of hepatic cancer.

DIAGNOSIS.

The best authorities have decided that ten per cent. of the entire population carry gall-stones. Moynihan is of the opinion that in nine out of ten cases of those who carry gall-stones, the disease is never recognized. Therefore, it is not a simple matter to make a diagnosis. The symptoms are at times vague; indigestion oft-times, is the only symptom, manifesting itself in one or more of the following ways: gastric catarrh. headache, neuralgia of the stomach, spasms, flatulent distention of the stomach and intestines and radiating pains through the chest and back. The above symptoms are produced by a reflex and vaso-motor disturbance. The same can be said in cases of appendicitis of the low grade inflammatory type. Autopsies have frequently revealed the true nature of the digestive disturbances, which otherwise would never have been accounted for. We have come not to rely on jaundice for our diagnosis, as it is absent in a great many cases. At times, pain is of an agonizing type, and will be the initial symptom. It will, in fact, come like a thunderbolt from a clear sky. This pain will pass off with equal abruptness. Kahr and others are of the opinion that gall-stone colic is the theory of inflammation. At times, the stones will make a peaceful journey, the patient will be unaware of their passage until they are found in the feces. A true or severe attack is easily recognized. The patient has agony depicted on his countenance; nausea and vomiting, accompanied by a death like pallor, and a cold clammy perspiration are present. In fact, all of the centres show extreme shock. Breathing becomes shallow and difficult. Add to the above picture, jaundice, and it is an easy matter to make a positive diagnosis; but, fortunately for the patient, and unfortunate for the diagnostician such is not always the case. Moynihan states that if one wishes to frame an epigram, it could be said with truth that the most common symptom of gallstones is indigestion. The practitioner will have to cease looking upon jaundice as the only reliable symptom, for it is of rare occurrence. When jaundice does occur, it is a grave sympton, showing an impaction of the common duct, which very much complicates a surgical operation and markedly increases the mortality. When the jaundice is remittent, Fenger

has shown and demonstrated that there is an impaction in the common duct. The duct dilates behind the stone, and a ballvalve action results. In such cases the stone floats in the dilated pouch, until it becomes re-impacted, which causes the intermittent jaundice. Impaction in the cystic duct, at times, but not often, produces jaundice by a spread of inflammation to the common duct. Jaundice may be caused from without the ducts. Courvoisier is of the opinion that the most frequent cause is due to malignant disease of the pancreas. For the sake of differential diagnosis, I will quote Courvoisier's Law "In cases of chronic jaundice due to the blockage of the common duct, a contraction of the gall-bladder signifies that the obstruction is due to stone: dilating of the gall-bladder, that the obstruction is due to causes other than stone." Courvoisier explains that the physiological cause of contraction is due to peritonitis or choclecystitis resulting in cicatricial cramping of the gall-bladder. Jaundice that is produced by malignancy comes on gradually and without pain. No intermission takes place, as is the case in gall-stones. Fever in gall-stone colic is noted for its abrupt onset, and for its equal abruptness in decline. It will jump from normal to 104 in an hour's time, and decline as quickly. Charcot in his original paper on intermittent hepatic fever depicted what he terms a steeple chart. Murphy has described his excellent method of palpation in the following language: "The most characteristic and constant sign of gall-bladder hypersensitiveness is the inability of the patient to take a full inspiration when the physicians' fingers are hooked deep beneath the right costal arch, below the hepatic margin. The diaphragm forces the liver down until the sensitive gall-bladder reaches the examining fingers, when the inspiration suddenly ceases, as though it had been shut off." When the liver is inflamed the above method causes a deep seated pain, and sends radiating pains through the liver and to the epigastrium. "Tumors of the gall-bladder are easily recognized. It is a simple matter to palpate the enlarged condition and at times the tumor can be recognized by inspection." Tumors of the gall bladder are caused more frequently by impaction of the cystic duct than any one condition. Later, the bladder shrinks from localized peritonitis. When the gall bladder is permanently enlarged, this fact is due to the great number of stones or to new growths.