same series, making 86.6 per cent. "The liver was the seat of metastasis in twenty-three cases; the peritoneum in eleven; pancreas in eight; bowels in eight; kidney and lungs each in four; pleura in three; spleen and diaphragm each in two; ribs, vertebræ, skull, ilium, femur, heart muscle, pericardium, abdominal wall, vesico-rectal cul-de-sac, and the ureter each in one case." Lymphatic involvement in Osler's forty-five cases as follows: "The gastro-hepatic glands, twenty-one times; the peritoneal, nine; posterior mesenteric, six; the supraclavicular and posterior mediastinal, two; iliac, bronchial, pericardial, anterior mediastinal and axillary, each in one case."

The symptoms in the case I report were fairly typical, with possibly two exceptions: First, the pain toward the last was not so intense as to require the use of opiates; second, there was no coffee-ground vomit, the growth being of the non-ulcerative type.

The prognosis is invariably fatal; the patient usually dies within a year. A small per cent of cases last eighteen months or possibly two years. In so far as treatment is concerned, I think I adopted the only rational plan of treatment, viz., the symptomatic plan.

Operations offer very little in this class of cases-practically they are never curative, but only palliative, and that generally for a very short time. Just consider for a moment the possibilities along the line of metastasis and lymphatic involvement, from the point of view of the stastics quoted above. (And those cases in which neither metastasis nor lymphatic involvement is found are rare, indeed.)

And again, in most every case when you open the abdomen you will find that general nutrition and the organs of nutrition have suffered more than you thought they had. Thus the process of recovery after this class of operations is notorionsly slow and unreliable.

In looking over the tabulated statistics, including all varieties of operative procedures for cancer of the stomach, we find that the operative mortality alone ranges from ten to thirty per cent. That is to say, from ten to thirty per cent of all cases operated on die from the effects of the operation itself. From the standpoint of the surgeon the operation is a success if the patient is able to be carried away from the infirmary. And in very few instances is there any attempt made to trace the case after that time. Even in cases where the so-called radical operation was performed, in the literature at my command I have found very few cases reported where the individual was kept under observation for a period of six months, to watch for possible

recurrence. In about ninety per cent of all cases you are obliged to use opium or some of its derivatives for the relief of the intense pain which occurs late in the case. Lavage is occasionally useful. The food or nutrition problem assumes the position of prime importance in these cases. The stomach early loses the power of complete digestion, and possibly later in the case loses almost all power of either digestion or absorption. Early in cancer cases, possibly before we recognize the true nature of the disease, we use antiseptics, digestant mixtures, and bitter tonics, but sooner or later we are obliged to resort to the use of peptonized or predigested foods-foods that are ready for absorption, and consequently do not tax the stomach. In cases of extreme irritability it is occasionally necessary to resort to rectal alimentation for a few days, then cautiously return to feeding by the mouth again, the variety, quantity, and quality of food to be administered in each case depending in part on the condition and peculiarities of the patient, and in part on the skill and judgment of the attending physician.

LOUISVILLE.

CHOLELITHIASIS.*

BY CARL WEIDNER, M. D.

Gall stones were first observed in 1565 by Johann Kentmann, of Dresden,' and have since been described by many observers. Th. Sömmering, in 1795, gave us the first accurate investigations into their structure, and good clinical accounts of the disease. F. A. Walter, a year later, carefully described and figured the rich collection in the museum at Berlin. Since the discovery of cholesterin by Fourcroy and Thénard we have an accurate knowledge of their chemical composition.

Gall stones are primarily mostly found in the gall-bladder, although concrements may be formed in other parts of the bile-channels. They are more or less firm, of various shapes, globular but mostly polyhedral, faceted, and smooth. Their size varies from that of a millet seed to that of a hen's egg; color white, yellowish, or mottled yellowish-brown to olive-green or black. Rarely found single, they occur in large numbers, many hundreds to thousands (7802, Otto's collection). Specific gravity is greater than that of water up to 1.966; they sink in

* Read before the Louisville Clinical Society, January 28, 1902. For discussion see page 193.

water. Most frequent in females, probably on account of pressure upon the bile-ducts by tight lacing and sedentary habits; rare in youth; most frequent after forty years. They may be homogeneous in composition, or compound-the latter having a nucleus, a shell, and a rind. They are the result of incrustation of an organic substance derived from the mucous membrane of the gall-bladder or bile-ducts. Stagna. tion of bile in the bladder favors this deposition and disease of the mucous membrane, leading to desquamation and degeneration of the epithelium, and in this debris the elements of bile, cholesterin, bile salts, and pigments and earthy salts of lime and magnesium are deposited. Formerly this mode of origin was thought to be purely mechanical, occurring in inspissated bile, but something else is needed besides this, and this something has for some time been recognized to be a catarrh of the mucous membrane, resulting in the increased formation of mucus, desquamation and degeneration of epithelium, migration of leucocytes, etc. Like in other inflammatory diseases, infection by various bacteria has been found to be the essential cause of this disease of the mucous membrane. It is in this relation that Naunyn spoke in Paris, in 1900: "The knowledge of cholelithiasis has undergone a complete transformation in the past ten years. Etiology and pathogenesis are at present governed by infection, and, supported by - this, surgery strives to monopolize the therapy."

994

Various bacteria have been found in the gall-bladder, such as bacillus typhi, bacillus coli communis, streptococci and staphylococci, bacillus pneumonia (Fraenkel), and the question naturally arises whether they may be directly or indirectly responsible for the formation of stones. Many chemical observations, combined with bacteriological examinations, favor this view, and artificial production of gall stones has been successful in the hands of several experimenters by infecting the gall-bladder with various forms of bacteria.

Naunyn reported a case of typhoid infection followed by gall stones in a boy fourteen years old. Mignot produced gall stones experimentally with various bacteria; Mijake also, by first narrowing the cystic duct and then injecting cultures of bacillus coli into the gall-bladder. Ehret and Stoltz, in collecting data on the relation of typhoid bacilli to inflammation of the gall-bladder and gall stones, cite an interesting case of Rokitski, who found typhoid bacilli in the center of fifty-eight small cholesterin stones, as well as in the purulent contents four weeks after the onset of the typhoid fever.

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Injections of typhoid bacilli into the ear-vein of a rabbit were made by Cushing. Two days later pure cultures of the bacillus were received from the gall-bladder and the duodenum. Contrary to the general views, he looked upon the bile as a good culture medium for most bacteria. DaCosta, in 1898, collected fifty-eight cases of typhoid cholecystitis, with thirty-nine deaths and fifteen recoveries. Half of the latter were operated successfully. At a later period, 1899, he reports three similar observations of his own, ending in recovery.

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Some authors believe that infection may take place through the portal circulation (Cushing, Fuetterer), others that it takes place from the duodenum, following the ducts upward (Gilbert, 1894; Richardson). Lettienne found bacteria in the gall-bladder, with lesions elsewhere in the body, in twenty-four out of forty-three cases; in the eighteen remaining cases the bile was sterile.

Richardson has observed agglutination and clumping of the bacillus typhi and bacillus coli in the gall-bladder, and suggests the probability that the clumps may form the nucleus of a gall stone, as in the case of Rokitski, mentioned above. He also agrees with Naunyn and others that simple presence of bacteria in, or their introduction into the gall-bladder are, as a rule, not sufficient to cause inflammation or stones, but that some other factor is needed, such as traumatism or some hindrance to the outflow of bile from the gall-bladder, as by stricture or compression of the cystic duct, a stone in the neck of the bladder, etc. (Riedel, Naunyn, Cushing, Mignot.) Osler mentions the infection of the gall-bladder and the possibility of gall stone formation by typhoid infection.

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Dauriac, Wunschheim, Eisendraht,' Marsden, and others have described typhoid cholecystitis. General experience seems to favor the conclusion that mild infection of the bile-channels and the gall-bladder may be counteracted by an antiseptic property of the healthy bile; that even gall-bladders containing gall stones may give rise to very little trouble as long as the cystic duct remains open and allows free access and egress of bile. When, however, the neck of the bladder or the duct becomes blocked by a stone the picture usually changes for the worse; in some cases the bile becomes viscid, thick, tarry. In the majority of cases the bile disappears and the gall-bladder becomes filled with mucus and serum, the hydrops vesicæ felleæ, or with pus. It has long been recognized that sedentary habits, excess in eating and drinking of alcoholics, tight lacing by pressure upon the cystic or common

ducts, etc., act as predisposing causes of the disease. Riedel, in addition, accepts some unknown disposition.

The symptoms and course of the disease differ very much in different cases, according to whether the stones remain latent in the bladder or whether they pass through the ducts successfully out into the bowel, or whether they become impacted in either cystic or common duct. Stones may remain for years in the gall-bladder without causing trouble and without being diagnosed. A larger stone having occluded the neck, "hydrops" will usually develop, and may remain for years or a lifetime. Acute inflammatory attacks of this hydropic gall-bladder with a stone blocking its neck, form, according to Riedel, the most frequent cause of hepatic colic. Moderate jaundice may or may not be present in these cases, caused either by contiguous swelling of bile-channels or by pressure of the distended gall-bladder upon the common duct. Thus far we have to deal practically with a localized disease of the gallbladder. Small stones may escape into the cystic and common duct, and into the bowel, with more or less severe symptoms of colic, and the condition may be temporarily or permanently relieved-temporarily by recession of the stone into the gall-bladder and arrest of the inflammatory condition; permanently if only small stones have been present and have all escaped into the bowel, or if the largest stone has passed and allowed the remaining smaller ones to follow in its course. This latter is what Riedel calls the completely successful attack.

Pain is one of the most prominent symptoms of gall stones. It is usually preceded by a sense of intense fullness in the region of the liver, that comes on several hours after meals. Pain is located over the liver, over the gall-bladder, toward the umbilicus, toward the right shoulder, sometimes toward the epigastrium; it is intense and paroxsymal in character, causing great agony, sweating, and collapse in some cases. Death has resulted on account of shock by the pain without any other lesion being present. Vomiting usually accompanies severe attacks; the contents of the stomach are followed by bile in large quantities; sometimes the presence of a gall stone has been detected in the vomited matter. The bowels are mostly inactive; the urine is scanty and high colored, particularly after an attack, and contains more or less bile color. Besides pain there is tenderness on pressure. This may remain several days after an attack, while pain leaves at once after the attack is over. Paroxysms occur repeatedly until the stone has been passed or has receded into the bladder. Then