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infrequently, the gall-bladder becomes nearly or quite obliterated.

When one sees a gall-bladder completely packed with calculi,
the contracted walls hugging them tightly, with little pockets

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S smith: terminal events in gallstone disease.

or nests under overlying adhesions, each nest occupied by a
gallstone which has ulcerated its way through the walls of the
gall-bladder, he appreciates the fact that he is viewing a terminal
event, and that at some time in the past that patient has passed
through a stormy period of cholecystitis — a period during which
a diagnosis of gallstones should have been made.

Pericholecystitis is a not infrequent terminal complication of
both acute and chronic cholecystitis. As the inflammation
within the gall-bladder varies in intensity, so does that without.
In the chronic form, the onset and progress of the disease may
be so insidious that symptoms are practically absent until the
presence of crippling adhesions to the stomach, duodenum or
colon, is made manifest by disturbances in function of the
adherent viscera. The adhesions in pericholecystitis, from either
an acute or a chronic infection of the gall-bladder, may cause so
great a degree of discomfort, of actual pain, or of disability, that
operation will be required for relief, irrespective of other lesions
produced by the offending gallstones.

Traction of the adhesions upon the stomach or duodenum may
produce an obstruction to the onward passage of food. In some
instances these adhesions are so general and so complicated
that the separation of them is attended by great diflSculty and
by slight promise of ultimate permanent relief. With no
obstruction to the outflow of bile, from either adhesion or stone,
gastrojejunostomy with no separation of adhesions has given
satisfactory results in two of my own cases. In one of these,
dense adhesions to the colon, which had produced a most
troublesome obstipation, were divided with relief of the colonic
obstruction. When, however, the adhesions are the cause of
pain or disability from traction on the gall-bladder, or from
angulation of the common duct interfering with the biliary flow,
or when a stone is present in the common duct, the separation
of such adhesions becomes a necessity. After the separation
and replacement of the adherent viscera, the omentum, as
suggested by Andrews,(io) should be upturned between the
biliary tract, on the one hand, and the stomach, duodenum and
colon, on the other.

The presence of a stone in the common duct must be looked
upon as a terminal event in the history of that stone, which, origi-
nating in the gall-bladder, as is generally, if not invariably, the
case, has later effected its passage, stormy though it may have
been, through the convoluted cystic duct. The frequency with

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which gallstones invade the common duct is much greater than
is shown by the statistics of the earlier investigators. Mayo(ii)
found common duct stone in 207, or 14 per cent, of 1,500
operations on the gall-bladder and ducts. Kehr,(i2) in 720
gallstone operations, foimd common duct stone in 137, or 19
per cent. Deaver,(i3) in 245 cases of gallstones, found stone
in the common duct in 56, or 23 per cent. Mayo Robson(i4)
reports that in his recent experience calculi have been foimd
in the common duct in 40 per cent, of the cases of gallstones
operated on by him. This latter percentage of common duct
stone is much higher than is shown by the general experience of
surgeons, and must result from either a more searching exami-
nation of the ducts by Robson than is customary with others,,
or from the fact that a more severe and complicated class of
cases fall into his hands. Robson further foimd that, in over
80 per cent, of the cases of common duct lithiasis, more than one
stone was present in the duct.

While a stone in the gall-bladder may, in many instances,,
produce only slight symptoms and inconsequential results, it
enters the common duct pregnant with power for the production
of terminal events of a serious and destructive nature. Having
at its extremities, on the one hand, the liver — on the other, the
pancreas; being the only excretory duct of the former, and
merging in a common outlet with the duct of the latter; the
common duct occupies a strategical position commanding the
welfare and integrity of both organs, each of which is essential
to life. The colic, announcing the passage of a stone along the
common duct, which must be considered as a terminal event in
gallstone disease, may vary in intensity from a scarcely appre-
ciable and transitory pain, to one of extreme degree, resulting
in utmost agony, in collapse and in death.

Blockage of the duct by stone, be it complete or incomplete,,
is fraught with dangers of the greatest severity, not to the
duct alone, but to the liver as well. In the absence of infec-
tion, the block produces results only of a mechanical nature.
The biliary channels proximal to the block, including the intra-
hepatic radicles, may become enormously distended, resulting
in marked biliary engorgement and enlargement of the liver, in
disturbance in its excretory function and in the reabsorption
of its products.

Blockage of the duct is frequently the determining factor
in the production of an infection which may involve the entire

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10 smith: terminal events in gallstone disease.

biliary tract from the minutest divisions of the intrahepatic
radicles to the ampulla of Vater. As in the gall-bladder, the
infections of the duct may present the greatest gradations in
severity. Exacerbations of cholangic infection, each marked
by its chill, its sudden high temperature with its rapid fall, and
its sweating — recurring at irregular intervals as a rule, but
occasionally with marked regularity — so closely simulate the
paroxysms of malarial intoxication as to be mistaken therefor.
In the highly infectious types, suppuration, ulceration and
perforation, may go hand in hand. With involvement of the
intrahepatic radicles, abscess of the liver, although infrequent, is
a serious complication often fatal in its results. Rogers(i5)
reports twenty such cases, in eighteen of which gallstones stood
in a causal relation.

It is in common duct stone, with its resulting cholangitis,
that jaundice is so generally a symptom. That jaundice has
held, and still holds, an unwarranted importance as a s3rmptom
of gallstone disease, is a deplorable but indisputable fact. In
arriving at a diagnosis of gallstones, valuable time is wasted, all
too frequently, in waiting for the appearance of jaundice. With
the general acceptance of the fact that jaundice, almost without
exception, is a late symptom, marking the occurrence of a termi-
nal event in gallstone disease, vdll disappear the greatest stumb-
ling block in the way of early diagnosis. That cholangitis and cho-
lecystitis may result from typhoid infection in the absence of
stone, and that such infection may progress to perforation, is
well established. Typhoid infection of a biliary tract already
occupied by gallstones, must be looked upon as a secondary
infection of most serious import.

Mayo Robson(i6) first called attention to the occurrence of
chronic pancreatitis as a complicating terminal event in gall-
stone disease. His subsequent writings and the experience of
many surgeons have shown that pancreatitis is a disease of
frequent occurrence and that in practically 80 per cent, of
the cases, gallstones have borne an etiological relation thereto.
The symptomatology of the disease is becoming well imder-
stood, and the diagnostic and confirmatory value of Cammidge's
pancreatic reaction is supported by those who have embraced
their opportunities for its frequent employment.

One decided advance arising from the present knowledge of
chronic pancreatitis and its pathology, is the recognition of the
fact that, in many instances of supposed cancer of the head of

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smith: terminal events in gallstone disease. 11

the pancreas, the swelling, induration and lobulation is the
result, not of malignancy but of inflammation. The differen-
tial diagnosis of the two conditions is not difficult, and upon
the decision must rest the prognosis and the question of opera-
tive treatment. Chronic pancreatitis will yield to biliary
drainage, either temporary or permanent, while malignant
disease must, of necessity, remain undisturbed in its progress
to a fatal issue.

The relations of the common bile duct to the head of the
pancreas and to the pancreatic duct, and of both of these ducts to
the duodenum, as well as the course of the lymphatics from the
gall-bladder to the head of the pancreas, are of importance in the
etiological relation of gallstones to pancreatic inflammations.
The sequence of common duct stone, cholangitis, and pancreati-
tis by ascending infection through the pancreatic duct, is well
established, while that of gall-bladder stone, cholecystitis, and
pancreatitis by direct lymphatic invasion, as contended by
Maugaret,(i7) seems equally certain.

Chronic pancreatitis presents two distinct pathological and
clinical pictures, the interacinar and the interlobular, depending
upon the location of the fibrosis, which is the essential pathologi-
cal process of the disease. In the interacinar type the fibrosis
occurs within the lobules and surrounding the glandular acini,
with early encroachment upon, and involvement of, the islands
of Langerhans, resulting in diabetes. Fortunately, this form of
pancreatitis seldom, if ever, follows directly from gallstone dis-
ease. It is in the interlobular type of chronic pancreatitis, with
the fibrosis primarily external to the lobule and only secondarily
slowly extending from the periphery into the lobule, with late
involvement, if any, of the islands of Langerhans, that gallstone
disease plays so important a part in etiology.

The operative results obtained by many surgeons prove that,
in the majority of instances, chronic pancreatitis can be cured by
the removal of the offending gallstones and the subsequent tem-
porary or permanent drainage of the biliary tract. At what
point in the course of a chronic pancreatitis, biliary drainage may
fail as a curative agent, is not established. Neither can it be
determined which particular case of gallstone disease will termi-
nate in pancreatitis, nor at what stage of the former the latter
will occur. The early surgical removal of gallstones, only, can
forestall the occurrence of a pancreatitis, with a possible diabetes,
as terminal events in gallstone disease.

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12 smith: terminal events in gallstone disease.

Of the many terminal events of gallstone disease, malignancy
is without question the most hopeless from the standpoint of
cure. That primary malignant disease of the gall-bladder and
ducts is preceded by gallstones in practically every instance,
is the experience of surgeons and pathologists. Ochsner(i8)
states that in primary cancer of the gall-bladder he has
always been able to get a history of gallstones dating back
many years, and in operating and in conducting autopsies in
such cases has invariably found gallstones present in the gall-
bladder. Brodowski found gallstones in all of forty cases of
primary cancer of the gall-bladder. Musser,(i9) in loo cases
of primary cancer of the gall-bladder, found gallstones in sixty-
nine, while Jayle found them in twenty-three out of thirty
cases of primary gall-bladder cancer. Siegert(2o) holds that
gallstones are present in 95 per cent, of all cases of primary can-
cer of the gall-bladder, and Beadle,(2i) at the London Cancer
Hospital, found gallstones present in all of the cases of primary
cancer of both the gall-bladder and the liver. Mayo, (22) in
1,800 operations on the biliary tract, found primary cancer in 4
per cent,, while Sherrill(23) places the percentage of cancer in-
cidence at fourteen, which is practically the same figure reached
by Schroeder.

In the face of all this accumulated experience, which har-
monizes so closely, and from which it would seem that but one
conclusion could be drawn as to the etiology of primary cancer
of the gall-bladder and ducts, the majority of the cases of
recognized gallstone disease are allowed to drift along, from one
terminal event to another, with the most optimistic indifference
on the part of the profession.

Other complications than those here mentioned — some com-
mon, others rare: some severe, others mild — are found as late
conditions in gallstone disease and, while no particular one
occurs with great frequency, when taken as a whole, the oc-
currence of serious and even fatal terminal events is extremely
common. It would seem that a due appreciation of the fre-
quent occurrence and the serious import of these complications
must lead to the surgical removal of gallstones, as a conservative
and prophylactic measure, long before the opportunity is given
for the onset of these terminal events. That this may be done
will require a more general recognition of the initial symptoms
of gallstone disease, with diagnosis based thereon, rather than
upon the symptoms produced by these same terminal events.

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bovee: gynecology and obstetrics in the united states. 13


1. Voelcker. Brit. Med. Jour., 1898, vol. ii, p. 1555.

2. Brockbank. Edinburgh Med. Jour,, vol. iu,p, 51.

3. Naunyn. Cholelithiasis, p. 144. Transl. New Syd. Soc.

4. Kehr. On Gallstone Disease, p. 99. Amer. translation.

5. Mosher. Johns Hopkins Hosp. Bull., Aug., 1901.

6. Deaver. Amer. Jour., Med. Sc, April, 1908, p. 536.

7. Deaver. Amer. Jour., Med. Sc, Jan., 1908, p. 37.

8. Deaver. Amer. Jour., Med. Sc, Nov., 1908, p. 625.

9. Moynihan. Gallstones and their Surg. Treat., p. 272.

10. Andrews. Jour. Amer. Med. Ass'n., Sept. 16, 1905.

11. Mayo, W. J. Annals of Surg., Aug., 1906, p. 209.

12. Kehr. Von Bergmann's Surg., vol. iv, p. 691

13. Deaver. op. cit. nos. 7 and 8.

14. Robson. Surg., Gynec. and Ohs., Jan., 1906, p. i.

15. Rogers. Brit. Med. Jour., vol. ii, 1903, p. 706.

16. Robson. Lancet, vol. li, 1900, p. 235.

17. Maugaret. Cholecysto-Pancreatite, Essai de Path., 1908.
18.' Ochsner. Gjmec. and Abdom. Surg., Kelly-Noble, vol. ii,

p. 289.

19. Musser. Boston Med. and Surg. Jour., Dec. 15, 1899.

20. Siegert. Virchow's Arch., Bd. cxxxiii, p. 125, 1896.

21. Beadle. Trans. Path. Soc., vol. xlvii, p. 69.

22. Mayo. Keen's Surgery, vol. iii, p. 966.

23. Sherrill. Annals of Surg., Dec, 1906.
234 Michigan Street.




Professor of Gynecology. George Washington University, Washington, D C.

To the President and Delegates of the Sixteenth International

Medical Congress:

As oflScial delegate from the American Gynecological Society
to this notable Congress of the world's great and noblest army,
the searchers of scientific medical knowledge and wisdom, I have
been asked to present to you a brief resume of the part my
country has been taking in this eflfort to gain increased knowl-
edge in medical science. My story will be limited to two sub-
jects, viz., Gynecology and Obstetrics. As the study of
medicine has progressed, the interesting subjects in the work have
remarkably increased in number. Necessarily, I cannot in this
presentation give consideration to all of even the most important

♦ Address prepared for the Sixteenth International Medical Congress at Buda-
pest, August 29 to September 5, 1909.

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14 bovee: gynecology and obstetrics in the united states.

ones. Neither will I be able to minutely discuss any one of them.
I shall mention new thoughts in regard to diseased states and
their treatment. Nor will I be able to refer to all this work done
during the three years that have elapsed since the fifteenth
International Medical Congress, as the younger workers in
America are imbued with a progressive spirit characteristic of
the country and have done much work. I sincerely hope I will
not be charged with partiality or bias in my not mentioning
some of this work.

I may safely state that conservative treatment of infections of
the uterine appendages has received a vast amount of considera-
tion. Barrett(i) and others have called attention to the fact
that inflammation of infected appendages is a result of nature's
resistance to infectious invasion, and therefore not a reason for
early operation in such conditions. F. F. Simpson (2) recom-
mends months of rest in bed rather than prompt surgical opera-
tion in this class of cases, claiming that if this is done a large per
cent, of them will be cured symptomatically if not anatomically.
Early in suppuration of the appendages vaginal incision into the
pouch of Douglas and thence into the pus collections with sub-
sequent drainage for one to two weeks is common practice now,
and in about one-half the cases a symptomatic cure is effected.
In the remaining half vaginal or abdominal section is done for
treatment of the crippled or imprisoned tubes and ovaries. In a
vastly large proportion of cases the abdominal route is employed.

Many of our principal gynecologists do not often attempt to
save portions of tubes and ovaries, believing symptomatic cure
will not be secured and that further surgical treatment will be
required. Manton, Brothers(3) and several others follow
largely the plan of saving portions of such structures, although
Brothers believes tubes containing pus should be excised. The
etiological relation of such conservation of structure to ectopic
pregnancy has not been fully determined. Many of the Ameri-
cans believe tubes formerly infected, whether surgically treated
or not, are potent causes of tubal pregnancy. Vineberg(4) has
reported a case of pregnancy in the stump of an excised tube.
The conservatism is not extended to the uterus if tubes and
ovaries have to be sacrificed. Here removal of the uterine body
is quite commonly practised, as the liability to adhesions to the
uterus, to chronic leukorrheal discharge, and even hemorrhage
is thought to more than counterbalance any advantages from
retention of that organ plus any additional shock from the ad-

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bovee: gynecology and obstetrics in the united states. 15

ditional traumatism. By many the belief that the ovary has an
internal secretion is strong. For myself, I refuse to entertain
such an opinion as so far as I am aware no structure in the body
not glandular in type has been found to have a secretion.
Whether or not this belief was the impelling force, we find the
work done by Glass and A. P. Dudley in ovarian implantation or
grafting enthusiastically pursued by Martin(5) and Morris(6).
Martin reports three cases of heterotransplantation and five of
homotransplantation, all of which he had done.' He insists that
this operation in women or the lower animals is no more danger-
ous if accomplished aseptically than any other small plastic
operation on the appendages; that homotransplantation of
ovaries will prevent the atrophy of the genitalia, which usually
follows castration. He is not so confident that heterotransplan-
tation is so reliable in this respect, nor in controlling the nervous
symptoms produced by the menopause. Transplanted ovaries
in abnormal locations will maintain their vitality, functionate,
and prevent the ordinary sequelae of castration. Martin says
both forms of transplantation have resulted in conception in
women. Morris' case was one of heteroplastic grafting of a
piece of ovary from one woman to another. Four years later
she was delivered of a living child. Peterson (7) has carefully
studied 173 cases in his clinic and states that at least 10 per cent,
of all women regularly menstruating at the time of operation will
be free from the troublesome symptoms of the artificial meno-
pause after hysterectomy with removal of the ovaries, and that
the percentage of women with no symptoms after similar opera-
tions will be slightly more than doubled if some ovarian tissue
be retained. The greatest percentage of suffering occurs in
women operated on between the ages of forty and forty-four
years, and the greater the amount of ovarian tissue conserved the
more will the symptoms of the artificial menopause be mitigated.
This is the accepted concept of the subject, yet but few American
gynecologists believe abnormal ovarian tissue should be con-
served for that purpose.

The Relations Between the Ovaries and Uterus, — Dael(8) be-
lieves his experiments on guinea-pigs and white rats disprove
Franklin's conclusion that menstruation is caused by the secre-
tory action of the corpus luteum. Dael concludes that double
ovariectomy in the pregnant animal always interrupts during
more than the first half of its duration. It is well known by
gynecologists that this deduction is not confirmed by actual

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16 bovee: gynecology and obstetrics in the united states.

experience in the human, as in woman pregnancy at various
stages has thus been tested and found quite able to resist such

Operations for the Relief of Pelvic Diseases of the Insane. —
Broun, (9) in a second report of his gynecological work among
women in the Manhattan State Hospital for the Insane, gives the
results of his operations on 411 patients. Thirty-two abdominal
operations were done for various pelvic affections. He states
that "Owing to the evident complexity of the etiology that
exists, even in the best circumscribed symptomatic groups, it is
clear that in the general estimation of the value of surgical in-
terference, it must be regarded as a procedure ranking with our
other therapeutic measures which aim to get the patient as
quickly as possible into a condition of bodily comfort and
physical vigor." He thinks the importance of early operation
and treatment is indicated by the proportional improvement, it
being for the first six months of insanity, 58 per cent.; for the
second like period, 33 per cent., and for the third, 26 per cent.
Manton, in his address as chairman of the section on gynecology
and obstetrics of the American Medical Association at its meet-
ing in June, 1909, is more sanguine than Broun, and his work has
extended over a period of twenty years. Clearly this is a work
productive of great benefit to insane women.

Adenomyomata Uteri, — Cullen(io) reports twenty-two cases
of adenomyoma uteri and states that 5 per cent, of all myomata
he has examined have proven to be of this character. This
statement will no doubt surprise the gynecologists that do not
microscopically examine uterine growths. These growths, con-
taining gland elements and myomatous tissue, form a distinct
type of neoplasm that is easily recognized microscopically.
The mucosa is always smooth and has an intact epithelium.
The glands appear normal, but the stroma of the mucosa is often
edematous or rarefied. The diffuse thickening in the uterine
wall consists of the characteristic myomatous tissue, but the
muscle bundles are much more interlaced than in the ordinary
myoma. Along the border of the growth the myomatous cells
gradually blend into the muscle cells. Usually the mucosa is not
encroached upon, but, on the contrary, is seen to have prolonga-
tions or even isolated portions ("islands") in the myomatous
tissue. Although associated with carcinoma of the cervix and
body of the uterus in five of the seventy-three specimens he has
examined, he considers them benign in character, and Welch has

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bovee: gynecology and obstetrics in the united states. 17

termed them **adenomyoma diflfusum benignum." In a tumor
of this Variety, I removed a few months ago, the interior was
the site of columnar-celled carcinoma. But a careful subsequent
examination revealed the presence of a stalk of the disease ex-
tending from the endometrium into the center of the neoplasm.
This latter fact somewhat lessens the force of the metaplastic
theory of cancer formation as suggested by Adami.

Fibromyoma Uteri and Anemia. — It has for several years
been the custom in America to estimate the hemoglobin per-
centage before operation for uterine fibroids. If the percentage
was found to be below fifty and no alarming complication other
than hemorrhage present an attempt was made to increase it
before performing the operation. If the symptoms or complica-
tions indicated the necessity for haste it was done in spite of the

Online Libraryof Rhodes. Spurious works AndronicusThe American journal of obstetrics and diseases of women and children → online text (page 2 of 109)