to me, despite the long and hard names Dr. Frank has quoted to induce us to believe, that the question is definitely settled. Like Dr. Schachner, I think there are a few links in the chain wanting. The presence of bacteria in gall bladders which contain stones would not be conclusive evidence, because if we can conceive the mechanical deposition or sedementation of organic salts in the dependent gall bladder, and a mechanical irritation resulting from their presence, we can also conceive that the presence of stones has induced the subsequent presence of the bacteria. We know that the colon bacillus has the power of traveling through the walls of the intestine, and under proper conditions it is quite supposable that there might be an accumulation of these bacteria under these circumstances. Unquestionably the dependent position of the gall bladder is one of the determining factors in the formation of gall stones, just as it is in the urinary bladder of old individuals where the bladder is not completely emptied. The same thing is true in gall stone formation, and this to some extent accounts for more females having gall stones than males, owing to the liver being more compressed by modes of dress, etc.

The recurrence of gall stones seldom takes place after operation where the gall bladder is drained by fastening it to the abdominal wall. The gall bladder becomes fixed in this position and remains permanently attached and sedimentation does not occur.

While the essayist did not go deeply into the question of symptoms of gall stones, it seems to me he is right in laying stress upon the history of continued digestive disturbances. Many of these people have been treated for years for indigestion or so-called dyspepsia. I believe the history of digest ive disturbances is of the greatest importance. Jaundice is of value when present, but its absence is of no special significance.

When it comes to the indications for

operation there remains a great deal to be said a great deal which will be necessary to be said before the physician and the surgeon can get. together and agree, as they seem almost to have done upon upon the question of appendicitis. I believe almost all of the foremost men among the physicians who make a specialty of internal medicine have come to the con-clusion that if they get a case of appendicitis operated upon early they avoid sickness and danger. Some of the latest writers, notably Richardson, have reached the same conclusion in gall stone disease; that whenever the presence of gall stones can be determined in the gall bladder by any train of symptoms, then the indication for operation exists, and by operating early the patient is saved from subsequent danger. Further, he calls attention in old individuals who have carried gall stones for a long time to the not infrequent co-existence of malignant disease, and that in many instances the malignant disease has been dependent upon the long continued presence and irritation of these gall stones. opinion, as soon as the symptoms determine that gall stones are present, the indication for operation exists.

In my

As to the kind of operation: Dr. Frank has rather championed extirpation of the gall bladder. I believe there is a tendency on the part of many of our foremost surgeons to take the same view. Dr. Roswell Park has presented the title of a paper which he is to read before the coming meeting of the American Medical Association, "Why Not Treat the Gall Bladder As We Do the Appendix," which, I suppose, means early and complete removal. I do not believe, however, that the large majority of surgeons will accept this for a long time to come, for the reason that, as the other gentlemen have pointed out, the chapter in gall bladder surgery has been so exceedingly brilliant, and relief afforded patients has been so satisfactory and the lack of danger has been so pronounced. Excision of the

gall bladder is the proper operation, if we make a proper differentiation as to cases. Mayo, in reporting 327 cases of gall stones operated upon, called attention to the recurrence of symptoms, or of continuance of fistulæ necessitating secondary operation, which was about 10%, and in each of these cases a gall stone was impacted in the cystic duct at the time of the original operation. The meaning is simply that when a gall stone is impacted in the cystic duct infiltration occurs into the walls and corresponding damage is done, leaving behind a tendency to stricture of the cystic duct. If this stricture becomes manifest, either the fistula you have established in draining the gall bladder will not close, or if it does close, the gall bladder will refill and you will have recurring attacks of pain signifying a distended gall bladder which empties itself into the common duct with difficulty. Where the cystic duct has become occluded, the gall bladder distended, cholecystectomy is not a particularly difficult operation. It is much like a fibroid uterus which raises up out of the pelvis; it is easily removed.

In other cases where it becomes necessary to operate secondarily for closure of the fistula by removal of the gall bladder, Mayo has pointed out that by stripping out the mucous membrane, leaving the wall of the gall bladder, the operation is very much simplified and is just as satisfactory.

DR. LOUIS FRANK: Dr. Bullitt has given many reasons why we should remove the gall bladder, doing a cholecystectomy where possible. Another reason is that after cholecystotomy we have a damaged and impaired organ which is attached to the abdominal wall and is likely to become reinfected through the same means that infection primarily occurred, and present again all the dangers to the patient that were formerly present with gall stones; therefore at the first operation why not get rid of all this by removing the gall bladder? Gall bladder surgery to-day

is probably to be compared somewhat with marsupialization of ovarian cysts as formerly practiced, and also with the treatment of fibroid tumors of the uterus formerly indulged in by many opertors; that is, bringing the pedicle out and stitching it to the abdominal wall. I believe we will in the future all agree that removal of the gall bladder is the proper operation when it is feasible and can be done without subjecting the patient to too many and too great dangers.

I mentioned in the paper that stasis was an important factor in the production of gall stones; that, however, is not the chief, nor only, factor; and to prove this we could cite many cases where there have been accumulations in the gall bladder without the production of stones. In all cases where stones have been produced, we find infection has taken place. If the common or cystic duct becomes obstructed, stasis is brought about and infection may readily occur; this has been repeatedly proven and is a question about which there is no doubt.

However, if com

I do not believe stone in the gall bladder is to be compared in its formation exactly with stone in the urinary bladder. One is an excretion, the other a secretion; their character is entirely different. pared, we may say that we find that the urinary bladder containing stones is always an infected bladder. There is residual urine which undergoes decomposition and which becomes infected. The presence of a foreign body may, of course, give a nidus around which a calculus forms, and without cystitis preceding the formation of stone. Even if we permit this analogy, however, I believe the argument of infection will hold good. In the gall bladder we have exfoliation of the epithelium, and infection precedes exfoliation, and agglutination of the exfoliated epithelium (the result of infection) precedes the formation of stone, and forms a nidus for the stone itself.

As to the cases which are to be op

erated upon: I believe that every case of gall stones should be operated upon as soon as the diagnosis is made, though not necessarily during an attack of colic, so as to avoid the dangers to which the patient may otherwise be subjected. With an infected gall bladder exacerbations are apt to occur, acute infection may be set up at any time, and rupture and gangrene may take place.

I certainly do not agree with Dr. Sherrill that cases of prolonged and persistent jaundice are the ones that ought to be subject to operation. Prolonged and persistent jaundice indicates cancer, and these are the unfavorable cases and should be let alone. There is nothing to be gained in operating upon such cases, unless it be to secure temporary comfort to the patient.

CANCER OF THE UTERUS.*

BY LEWIS S. MCMURTRY, A.M., M.D. Professor of Gynecology and Abdominal Surgery in the Hospital College of Medicine.

LOUISVILLE, KY.

The appalling frequency and high death-rate of cancer of the uterus commend this subject constantly to our attention and demand from pathological and clinical investigators the most earnest research.

All who have studied the subject of cancer from a statistical standpoint in Germany, France, Great Britain and the United States of America concur in the assertion that cancer is markedly on the increase in all civilized countries in recent years. This fact, together with the notorious inadequacy of all modern methods of treatment, both medical and surgical, has stimulated research in all countries. The fact that the Emperor of Germany has lost both his parents from this disease, one being the sister of the King of Great Britain, has lent its influence in those countries to urge on the study of the cause and treatment of this malady. The large donations from wealthy citizens of the United

*Read before the Louisville Medico-Chirurgical Society, May 16, 1902. For discussion see page 76.

States of America toward original research in disease recently, together with constantly demonstrated benefits from our new knowledge of tuberculosis and diphtheria, have given power and force to these investigations in our own country.

The limits of this paper do not permit an extensive disquisition upon the pathology of cancer, the various phases of its development, the theories as to its cause, and the many diverse methods of surgical treatment as applied to the various sites elected by the disease. It shall be my purpose to present for your consideration rather some practical observations upon carcinoma of the uterus, the result of an extensive experience with the disease for a number of years. As you all know, I have made no studies in the histology of the disease, but will treat the subject entirely from a clinical standpoint.

William H. Welch, while preparing an article upon Cancer of the Stomach for Pepper's System of Medicine, made a large collection of cases of primary cancer (numbering 31,000 cases), in European countries and in America, where statistics would be reasonably reliable, showing the comparative frequency of primary cancer of the uterus. He says: "If the sum total of all the cases be taken, the conclusion. would be that about one-fifth of all primary cancers are seated in the stomach, and somewhat less than one-third in the uterus. Even if allowance be made for the apparently too low percentage of gastric cancer in the Vienna statistics, I should still be inclined to place the uterus first in the list of organs most frequently affected with primary cancer." Cullen states that during a period of six years at Johns Hopkins Hospital he met with 182 cases of cancer of the uterus; 128 were of the squamous-cell type, 19 adeno-carcinomata of the cervix, and 35 adeno-carcinomata of the body of the uterus. These two estimates, that of Welch based upon 31,000 cases, and that of Cullen upon 182 cases, give a fair idea

of the partiality shown by this fatal malady for the uterus as its favorite locus. The statistics of Cullen also give an idea of the comparative frequency of the various types of cellular development, the squamous-cell epithelioma of the cervix being the most common variety. According to my own personal observation, Cullen's estimate of the frequency of cancer in the body of the uterus is excessive. In my observation the proportion of cases of cancer of the body of the uterus is very small when compared with the common manifestation of cervical disScarcely any practitioner of

ease.

when seen a few times. The age of greatest prevalence being from 40 to 50 years adds to the facility of diagnosis. Pain is such an inconstant symptom that it may almost be disregarded as a diagnostic feature of the disease. The one symptom most conspicuous from beginning to end is hemorrhage. I have been enabled in more than one case to make the diagnosis when the manifestation of the disease consisted in a small papule on the cervical surface while operating for laceration by its profuse bleeding when incised. The early recognition of the disease, so essential for any attempt at successful

medicine goes through many days of active work without encountering several cases of cancer of the uterus; while with those whose work is like my own, devoted in most part to gynecological cases, this disease is with us always.

It seems to me almost superfluous to take any part of our time this evening in reciting the symptoms of cancer of the uterus. They are so typical and pronounced that the diagnosis may be readily made. The symptoms of hemorrhage and anemia, of emaciation and cachexia later on, render the clinical picture distinct and readily recognized

treatment, is almost invariably accomplished by examination for the cause of hemorrhage. The greatest obstacle to early diagnosis has been through all time, and continues to obtain, in the innate modesty and reluctance of women to seek medical advice early for diseases of the sexual organs. All the cases of uterine cancer that I have seen very early in the course of development were discovered while making an investigation for some complicating condition which had compelled the patient to seek professional aid. The microscope is a valued aid in diagnosis. The

familiar illustration of the disease is a woman about 50 years of age, who several years after the menopause discovers a renewed flow. Regarding it as some late manifestation of the change of life, it is allowed to go on for months before its serious import is realized. And the equally familiar picture presented to the surgeon on examination is an uterus fixed by infiltration and accompanying exudate into peritoneal surfaces, with a crater at the uterine cervix. The cachexia includes anemia which is peculiar, and quite different from the anemia of ordinary hemorrhage or internal suppuration. The toxemia of cancer is different from that of infection by the staphylococcus and streptococcus. A study of early cases will convince one that the disease is conspicuously local in its incipiency. It is only after extensive histological change that the systemic symptoms appear.

an

If one will take the time to go through the voluminous literature of carcinoma he will be impressed as much with the ingenuity of theorists as with our scant knowledge of the subject. Many ingenious theories have been evolved, and the most recent literature attributes the increased prevalence of the disease to various dietetic and climatic conditions. The increased consumption of meat as a food in some countries is mentioned by Roger Williams in The Twentieth Century Practice of Medicine as a prominent factor in the causation of the disease, while Lyon, of Buffalo, read a paper in the spring of last year declaring that the disease was caused by eating raw vegetables. Heredity has long been regarded a potent factor in the causation of the disease. After an elaborate study of this subject by Cullen, in which he traced the family history in a large group of cases, in only a comparatively small per cent. had any member of the family suffered from any form of cancer; in more than 82% any hereditary tendency could be excluded. In my limited field of observation I have in recording my cases

made it a point to inquire into this feature of the disease. Cancer is such a common disease that it is somewhat difficult to find many families who have not had one or more instances to appear in two preceding generations, but I have long been convinced from my own investigations that heredity was not a potent causative factor, if a factor at all, in the etiology of cancer.

Cohnheim advocated the theory of embryonic inclusion of epithelial elements. According to Cohnheim, during fetal life portions of epithelium become nipped off and included in the connective tissues, giving rise by stimulated activity in after years to cancer. Ribbert claims that carcinoma begins at first by an active increase of the connective tissue just beneath the epithelium, and not to the embryonic cells which have been nipped off. We could recite numerous similar theories that have been presented by histological pathologists, all of which are purely fanciful and do not explain the phenomena or coincide with the evolution and progress of the disease.

Following the analogy of modern research, it is but natural that this disease should be attributed to parasitic origin. At the present time this is the burning question with students of the pathology of carcinoma. Important investigations are actively in progress and important contributions are being made to the histological study of cancer. All the various phases in the life of the cancer cell, its nucleus and protoplasm, are being minutely studied. The literature of the subject is already voluminous. The hypothesis of the parasitic nature of cancer has been pursued in every direction, and it remains only an hypothesis. I know no statement which so well expresses my own views, after rather an extensive study of the subject, than is found in these words of Councilman (Boston Medical and Surgical Journal, Vol. 132, p. 256): "A general consideration of the articles referred to here shows that the question is still undecided, but by far