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(4) An infection of the biliary tract above a ligated duct could not come by the ascending route. (5) Cases of enterites have been produced experimentally by the feeding of arsenic, etc., then some easily recognized organism as the bacillus prodigiosis introduced into the bowel and within a few hours this organism has been recovered by culture from the bile contained in the gallbladder.

Up to this time all of our lines have converged to one point, the establishment of an infection within the biliary tract. An infection having been established our lines again widen, for the life history of an infection within the biliary tract is quite a varied one, depending as we have stated, upon the virulence of the organism or the resistance of the individual. If the organism is still virulent after having successfully passed the mucosa of the intestine and the liver it will give rise to an acute cholangitis or cholecystitis and the history and symptoms will be those of any acute infection, with the localizing symptoms in the upper right abdomen. There is one point worthy of mentioning here, and that is, that an acute infection in the gall-bladder does not give rise to so severe symptoms as an infection of the same virulence elsewhere. This is explained by the absence of lymphatics in the gall-bladder, and also by the very great elasticity of the gall-bladder.

The usual course of events is that organisms arriving in the bile still alive have had their virulency so reduced by the protective barriers that they have been compelled to pass, that they give rise to only a very moderate inflammatory reaction. This reaction very commonly passes unnoticed by the patient, but it is the most important factor in the etiology of gall-stones, as it is also the most important matter in the complication of gall-stones.

As to the modus operandi of the forma tion of gall-stones, it has been demonstrated that a low grade infection is of itself not enough to give rise to gall-stones. The unobstructed flow of bile into the intestines seems to be able to wash away this infection. Cultures introduced experimentally into the unobstructed gall-bladder have very rarely if ever been successful in producing gall-stones, but Cushing as well as others, has been able to produce gall-stones experimentally by the introduction of bacillus coli or bacillus typhoid into the gallbladder, the cystic duct of which had been previously ligated. It was the work of Naunyn (6) which first demonstrated that a low grade inflammation in an obstructed gall-bladder was the chief cause of biliary

calculi. This work has been proven by the later work of Aschoff (7), Adami (5), Welch (4) and many others, and it is now fully accepted that the gall-stones owe their origin to the intractions of two factors. First, the stagnation of bile. Second, the introduction of bacteria into the same with the development of a catarrh of the biliary mucous membrane. This catarrhal inflammation is accompanied by desquamation of epithelial cells and the subsequent degeneration of same. It is this catarrh which leads to the production of cholesterin. It also favors the discharge of calcium salts into the bile and the interaction of those with the bile pigments to form precipitated bilirubin calcium. As Naunyn points out, the calcium of the bile has like origin to the cholestrin, viz., from the inflamed mucus membrane.

He found further that calcium salts added to normal bile led to no precipitation; that we have in short the same phenomenon that we have to deal with in the formation of other calculi, the favoring action of a colloid substratum. Thus it would seem that the calcium salts and cholesterin are both essential to the formation of calculi and both have their origin from the inflamed mucous membrane.

The cholesterin has its origin from the degenerating desquamated epithelial cells. Microscopically these are seen to contain some double contoured myelin droplets. With disintegration of these cells the myelin is set free, and under the action of pure alkalies the cholesteryl oleate is disassociated. The oleic acid combines to form soluble soaps. The cholesterine becomes precipitated.

In the vast majority of cases these stones have their origin in the gall-bladder simply because conditions which lead to their formation can best be brought about in the gallbladder. If later one of these stones became lodged in a common duct or a common duct becomes obstructed from any other causes, they may form as readily in the hepatic duct as in the gall-bladder.

While it is beyond the purvey of this paper to discuss the symptomology diagnosis and treatment of these infections, we cannot resist the temptation to say just a few words.

The symptomology is quite varied. One must recognize that symptoms arise from two different sources: First, a group of symptoms due to purely mechanical causes; secondly, those arising from infections. The first group are usually very easily recognized, but it is the second group that are

by far the greater importance. If one but remember the frequency of these infections, together with the fact that a severe infection here may give rise to but slight symptoms for a time; if one is careful in the taking of his history in the physical examination of his patient, together with the careful examination of blood, he will usually land right, for as Dr. Mayo has so aptly said the innocent gall-stone is a myth. Another thing be remembered is the fact that it is not nearly so much the gall-stones as the ever present infection that concerns us. The intelligent treatment of cholelithiasis presupposes a clear conception of (1) the pathology of the disease, of (2) of the means of treatment at our command and the objects attainable by their use. To attempt by internal medication to dissolve a gall-stone that is insoluble; to cause the passage through the biliary ducts of a gallstone to cure supposed gastric symptoms by measures directed to the stomach when the cause of the symptoms is adhesions about the gall-bladder, or a condition within the biliary tract, is as futile as it is irrational.

REFERENCES.

1. Diseases of Stomach. Surgical Treatment. RobsonMoynihan's.

2. Cirrhosis. Sajous Annual, 1898.

3. Quoted from Naunyn.

4. Johns Hopkins Hospital Bulletin, 1891. ii, 97.

5. Proc. Roy. Soc. Lond B., 78: 1906, 359.

6. Treatise on Cholelithiasis, Naunyn, 1896.

7. Verhandl. d. deutch path. Gesell., 10, 1907.

DISCUSSION.

DR. JABEZ N. JACKSON: I want to call attention to one point which I believe to be of value to those who are doing surgery, and that is a recognition of the fact that all of these cases of gall-stones are infections to begin with, and that these infections come more often to the bile through the radicles of the portal vein, but not so often through the systemic infection of the hepatic artery. In appendicitis of the suppurative type we may have thrombo-phlebitis, a breaking away of a clot, and a liver abscess. A lesser infection, which is not susceptible of producing pus, can break away from the ordinary catarrhal appendix, and secondarily, infect the gall-bladder, which presents the same favorable anatomical site for infection as is found in the appendix. It is a frequent coincidence in which surgeons have operated on patients for appendicitis and found gall-stones also, in which cases they possibly may have made a diagnosis of both appendicitis and gall-stones and found both, but there are many other instances in which we have had humiliating experiences. I have had the experience twice of having made a diagnosis of appendicitis, operated on the patient, and two or three days after the operation the patient has developed a typical attack of gall-stone trouble. will remember, Dr. Charles Mayo was operated upon for appendicitis, and four days after the operation he had an attack of gall-stone colic. That has been my experience. An old chronic appendix, I believe it is one of the focal points through which the gall-bladder becomes infected, and is one of the remote causes of infection of

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the gall-bladder and of gall-stones. When, there

fore, we have a patient who has had chronic appendicitis, we should bear that in mind and not be content with a diagnosis simply of appendicitis, but we should be sure that the patient has no trouble about the gall-bladder which possibly may be infected through the appendix.

DR. JOHN F. BINNIE: I fully believe the majority of cases of gall-bladder diseases (cholecystitis, of which gall-stones are an accident) and ulcer of the stomach are due to the same thing, namely, the absorption of an unaccustomed quantity of poisons or poisonous material from the sewage system of the body, that is, through the portal circulation, as has been pointed out by Dr. Nesselrode. We have what Moynihan and others call appendical indigestion. A simple appendicitis is the most common inflammatory lesion we know of in connection with the portal circulation, which would supply the poisonous materials necessary to infect bile or to dam it back from the veins into the stomach and cause ulcer of the stomach. Typhoid is a common precursor of gall-stone disease, it sends poisons through the portal circulation, these poisons being eliminated through the bile and causing cholelithiasis. Given any infectious disease of the sewage system of the body produces an unusual quantity of poisonous material, to be thrown into the blood, and passed through the liver (I consider the liver the sewage farm), it will furnish enough infective material to cause gall-bladder disease, and if a lot of that tainted blood is driven back from the gastric vein into the stomach, we can have gastric ulcer produced. Post-operative hemorrhages seem to be due to reverse embolism in the gastric veins. These hemorrhages are from lesions of the mucosa of the stomach, which recover exceedingly promptly, just as promptly as acute ulcer of the stomach recovers, if it does not kill the patient in the meantime. In a whole lot of cases I believe infection getting by the portal circulation is dammed back into the stomach mucosa, and causes symptoms of ulcer of the stomach without causing demonstrable lesions. The common cause away down in the belly for the poison is appendicitis, hence the term appendiceal indigestion.

DR. D. A. MEYERS: One point in the etiology that the doctor did not mention is the fact that women are more subject to gall-stones than men, more especially women who have been through pregnancy. While all of these surgeons have been telling us that infection is the primary cause in all of these troubles, to my mind there is always more or less bacterial life in the ducts and gall-bladder. Why is it not possible for traumatism to set up the first cause, infection then to take place, and form the catarrhal condition that the doctor spoke of, and then the stones become accidental?

DR. HOWARD HILL: I wish to call the attention of the members to an anatomical point, namely, that in certain cases you will find a distended gall-bladder, but with absolutely no obstruction in the biliary tract, and the bile will flow through in an hour or so after cholecyscostomy. I have come to the conclusion that this is due to an abnormal disposition of the peritoneal fold which surrounds the so-called pelvis, and that whenever the gall-bladder becomes distended beyond a certain point, it compresses the cystic duct and the gall-bladder is distended by its own secretion. Every surgeon who has done much abdominal work must have met with cases of

distended gall-bladder without any stone, when immediate biliary secretion is established through the cystic duct, showing it could not be due to the swelling of the mucosa. I saw one case, a child three years of age, brought to the hospital vomiting with symptoms of intestinal obstruction. On opening the abdomen the gall-bladder popped out, and just as soon as it was opened and drained and bile washed out, the child recovered. curiously enough cultures were absolutely negative. I think when the peritoneal folds are abnormally disposed in such cases there will be pressure of the gall-bladder, or compression of the lumen of the duct, and I would suggest that this one form of stasis may be responsible for quite a little trouble.

DR. C. C. NESSELRODE (closing): I feel gratified at the kindly remarks that have been made on my paper. The only regret I had was, and I know you will appreciate it, that within twenty minutes one cannot present the question of gall-bladder infection, even the pathology and the etiology, and there are a number of things to be mentioned that cannot be discussed at this time. I should have discussed what Dr. Jackson has called attention to, and that is the association of appendicitis with gall-stones or cholecystitis. That comes under the same group of infections as those following typhoid fever drainage is through the portal circulation. The tendency has been to recognize the similarity that exists between the kidney and liver as an excretory gland, and especially an excretory gland for bacteria. In a general way, nature is destroying the bacteria which are constantly getting in. The blood entering the kidney and liver contains a large number of bacteria. These bacteria would be dangerous if allowed to go into the general circulation.

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Our attention has been called by Dr. Binnie to one thing in particular which I want to emphasize, namely, that the gall-stones are merely an accident. That, it seems to me, is very aptly

put. The gall-stones themselves are a sort of accident.

Another thing to be emphasized is that one in treating these lesions is not treating particularly gall-stones, That is the reason there are not so many gall-bladders amputated today as formerly. Of course, you remove the gall-stone, but the real thing you treat is an infection, and the drainage is the very important thing in this type of cases. The stones themselves are foreign bodies there and are removed because they give rise to some mechanical symptoms.

As to the question of a larger number of cases of cholelithiasis occurring in women than in men, that is undoubtedly true, and the belief is becoming very generally recognized now that the portal circulation is the entry of these infections, and when we consider that women are more sedentary in their habits than men, we can easily realize how women are much more subject to constipation than men. A pregnant woman may

be subject to constipation more so than a man, and there is a general stasis of the intestinal canal that must cause a very much more active migration of the bacteria through the mucosa of the intestinal canal into the portal radicles than men who are active and whose bowels are moving regularly.

Stasis due to ptosis is one of the great factors in regard to the migration of bacteria through the intestinal wall. The question of ptosis of the abdominal viscera would furnish material enough for four or five papers.

The proposition Dr. Hill has made is a very apt one, and it would seem perfectly rational and in accordance with the suggestion that the cultures from this type of gall-bladder are sterile; that it is a purely accidental occlusion, and in those gall-bladders you will find occlusion. If that were allowed to go on, one of two things would happen. If you had infection engrafted, you would have empyema of the gall-bladder, but if no infection takes place you would have typical hydrops of the gall-bladder because you have no drainage established.

NEEDLESS TRAUMATISM IN RECTAL SURGERY.*
W. H. Stauffer, M. D., St. Louis, Mo.

NE of the results of the use of local anesthesia has been to teach us that many surgical operations can be performed satisfactorily with very little manipulation. It is not my purpose to discuss the use of local anesthesia in rectal and anal surgery. Suffice it to state that it has a definite field in properly selected conditions. The very liberal nerve supply of the lower bowel renders it particularly difficult to make an examination of the rectum. Pain, false modesty and misrepresentation keep many persons from consulting their physician for what is often considered a humiliating disease.

It is unscientific and a gross injustice for any physician to prescribe without an intelligent examination; yet fifty per cent of my patients inform me that an examination was not even suggested.

The unnecessary display of archaic and formidable instruments in the doctor's private show case often frightens the sufferer and an examination is refused. A good light, an educated finger, a small anoscope, and the aid of the pathologist, should enable us to diagnose all the diseases found in this region. The technique must be learned by observation and experience, and cannot be obtained by referring to textbooks. Much tact, a fair knowledge of human nature, and the proper use of a little cocaine will enable you to make a painless examination in most cases.

By placing the patient in the inverted position, the use of the proctoscope has been much simplified, both as to the instruments employed and the comfort of the operator. The complicated pneumatic proctoscope unless used by an experienced

diagnostician is dangerous and unnecessary. It is much safer to make an exploratory abdominal incision than it is to distend a diseased colon. A number of cases of socalled pneumatic peritonitis have been reported. The amount of information elicited does not warrant the risk incurred.

Having made a diagnosis and decided that operative measures are indicated, the surgeon should select the procedure best suited to remove the disease, require the least time, and cause the least possible pain.

An experience of eight years devoted exclusively to the treatment of diseases of the colon, rectum and anus, has taught the writer that his chosen field has been much neglected. Most of the text-book articles and illustrations have either been borrowed or stolen, and but few operators have dared to suggest anything out of the ordinary. The review of the operative technique in the more frequent diseases of the lower bowel with the object of eliminating needless traumatism is the primary object of this paper.

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In the American Text-Book of Surgery, page 755, I note the following: "After an anesthetic has been administered the sphincter ani should be stretched by the introduction of both thumbs, and the tension should be kept up until the muscle is felt to give way. In Burghard, page 670, I read: The index finger of each hand is inserted and forcible dilatation of the anus is carried out by separating the fingers gradually and with some force; this should be continued until the resistance of the sphincter is overcome." Kocher, page 662,

edition 1911, advises the following: "If an operation is to be performed it is essential that anesthesia should be complete to allow of the anus being fully stretched so that the upper bunches of hemorrhoids can be thoroughly brought down into view."

After operating on over five hundred cases of hemorrhoids without paralyzing the sphincter ani, I have arrived at the following conclusions: First. Dilatation exceeding one inch is unnecessary as a preparatory step in any operation on the rectum or anus. Second. Needless dilatation ruptures the muscle fibres, separates the nerve endings, invites infection, increases post-operative pain, frequently produces partial incontinence and prolongs convales

cence.

The so-called nerve blocking method of local anestheisa as advocated and practised by Drs. Tuttle, of New York, and Hirschman of Detroit, is not necessary unless you wish to mutilate the sphincter before you

operate. Hemorrhoids can be easily everted by packing the anoscope with gauze, removing said instrument and applying traction to the gauze. If the hemorrhoids are not ulcerated or badly congested they can readily be removed by the aid of pressure anesthesia, said anesthetic being injected at the muco-cutaneous line. The dressing and after treatment has been much simplified by the use of a finger cot filled with cotton instead of the rubber tube or gauze packing.

The time has gone by when any up to date surgeon is found guilty of paralyzing the sphincter to cure an anal fissure, when that painful condition can be so easily relieved by local treatment, removing the socalled sentinel pile, or dividing a few of the muscle fibre by the aid of local anesthesia. Bismuth paste and the employment of the X-ray have taken the place of the probe in diagnosing complicated fistulas. The sphincter is allowed to remain intact and is never divided unless there is a reasonable prospect that the severed muscle-ends can be properly coapted and its function restored within a week.

The various catarrhal conditions and ulcerations should be properly diagnosed and treated constitutionally and locally, and no undue violence to tissue should be countenanced. A Kraskie operation for the relief of a syphilitic or tubercular stricture is unjustifiable and does not reflect credit upon the operator. Time forbids the discussion of the excision of the colon for constipation, as practiced by Mr. Lane of London, or Dr. Samuel Gant of New York.

And what is there to be said to the credit of the mutilating operations for the removal of malignant conditions. The facts should be plainly stated to every patient and he be allowed to take his choice between a radical procedure or palliative

measures.

A careful study of the statistics reveal the fact that few surgeons or members of his family are found among the number who were willing to take the risk.

In conclusion, I feel justified in asking that you treat the lower bowel with as much you as general surgeons and gynecologists care as you do a tumor of the breast or an ovarian cyst, and your results will be equally satisfactory.

Humboldt Building.

DISCUSSION.

DR. JOHN F. BINNIE: I want to speak about dilatation of the sphincter ani, and why so many of us want complete dilatation of this muscle. In days of yore, before anesthetics were com

monly used, the poor sufferer was put over a stool of hot water and strained and strained until the piles came out. The surgeon took hold of the pile with forceps, tied a piece of string around the pile, clipped off the end, the stump went inside the sphincter, and the patient was put to bed. Frequently the ligature would slip aud the patient would bleed internally. According to the old text-books, if the patient was bleeding, dilatation of the sphincter was done to find and ligate the bleeding point. That is the reason why we have kept up dilatation of the sphincter ani.

DR. W. H. STAUFFER (closing): The object of the paper was to bring out the questions discussed. First with reference to the use of a tube. I have never been guilty of using a tube. All I use is an ordinary finger cot after operating on the rectum, and I do that for the simple purpose of keeping the two sides of the rectum, where I make the incision below the hemorrhoids from coming together. This simple rubber tissue keeps them apart. As to hemorrhage, I have no fear if the ligatures have been placed properly.

I appreciate very much the remark of Dr. Blesh with reference to the general surgeon in relation to this work. They have always done good rectal surgery, and they will always continue to do So. My principal criticism is with regard to the after-treatment in many of these cases, and occasionally there is a temptation to convert a minor operation into a major one when it is not indicated.

With reference to the treatment of fistula, I am very glad indeed that question was brought up. There is scarcely a day but some one come to my office and makes a remark like this: Doctor, I would be operated upon if I thought I would not have incontinence; a friend of mine had incontinence after operation. I wish to say that no sphincter should be divided unless you have the assurance that that sphincter is going to be coaptated within a week, and that statement calls for an explanation. You probably know the method of our itinerant friends in operating for fistulas. It is true they do some good work, and they should have credit for what they do. They use a rubber ligature and remove the fistula from above down, and in some of the cases get well with complete continence. In modification of

their method I divide the fistula with all the pockets and by means of curettement clean them out. I divide the fistula from above down until I get to the sphincter. I do not divide the sphincter. I pack it carefully at each dressing until I secure union to the sphincter, and then by the aid of local anesthesia I divide the sphincter. I will try and illustrate how we do that (illustrating). Where we have a horseshoe fistula and pockets in every direction, we have a mass of cicatricial tissue and the sphincter will not unite end to end, and the best you will get will be a ligamentous union between the ends of the sphincter and partial incontinence. It is a very difficult condition to repair. There is a large amount of cicatricial tissue of low vitality which predisposes to ulceration and ulceration predisposes to malignancy. If you do not divide the sphincter until you have restoration of the other tissue involved, you will get end to end union. You will get it every time if you do not disturb your anatomical relations, and you will not have so many cases of incontinence. I dare say you won't have any if you dress the patients yourself and follow up your cases carefully. The patient does not have to remain in bed except for the first few days, and an end to end union will repay you for your efforts.

The technic of the treatment of fissure is very simple. You make a funnel of the anus, using cocaine, after having put the patient in the exaggerated Sims' position. You can evert the fissure, and after the application of carbolic acid or tincture of iodine, you can clip off the sentinel pile and divide half of the fibers of the sphincter, thus relieving the spasmodic constriction. By putting the patient on bromides for two or three days, you are rewarded by having a satisfactory result without having inflicted any undue amount of traumatism.

The technic of the operation for hemorrhoids is very simple. We simply evert them one by one and divide the tissue at the muco-cutaneous margin, then take a piece of gauze and make gauze dissection, next divide the nerve endings and transfix the hemorrhoids after the Allingham or Mathews method. You should attend to one at a time. The operation can be done in less than ten minutes. Allow your patient to get on his feet to void urine. He can take a bath on the second day, and go to work in a week.

DOES ANCHORING THE KIDNEY RELIEVE THE NEUROSIS. Joe Becton, M. D., Greenville, Texas.

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T has been wisely said, "There are many operators, but few surgeons.' We all know an army of splendid executioners, but a limited number of careful, conscientious diagnosticians.

About one-fourth of the human family are going around with a wandering kidney and do not know it; many are found by mere accident while bathing or dressing, or by the family physician during an examination in ordinary bedside work.

The most of these cases are giving no trouble and never have, and the diagnosis being especially easy in the lean subject, and almost any of the operations devised by the various surgeons being comparatively

easy, and the mortality low, it is an operation of greater frequency with the "quasi" or would-be surgeon than an invasion of the upper abdomen, he never giving a thought beyond the spectacular proceding except the fee.

It should be the duty of every surgeon to operate for the relief of his patient and the enriching of his coffers be secondary to human life. To diagnose a movable kidney and be satisfied is indeed superficial, almost unto criminality-one should look for enteroptosis of other viscera, especially the stomach and transverse colon-also kinks, Jackson's membrane, adhesions in and around the cecum, the appendix and ovary.

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