I do not propose to go over the symptomatology of gall stones and gall-bladder disease at present. That has already been done by many good men, and I simply now wish to call attention to the excellent chart which Professor Brewer has published in the transactions of the Congress of American Physicians and Surgeons in the volume for 1903.

Infection of the gall bladder is so easily accomplished from either the colon bacillus or the typhoid bacillus, that one should always be suspicious of intestinal disturbances in the upper abdomen, particularly in patients who have had typhoid fever, and although we know stones may exist in the gall bladder in great number, not presenting symptoms calling attention to them during life, and found as surprises at the post-mortem table, there are patients who have suffered for years with suspected simple indigestion, duodenitis, etc., who really are suffering from infection of the gall bladder containing stones. The presence of stones offers increased opportunity for infection, but infection may come without the formation of calculi, and much can be done in the way of operative procedure directed towards the relief of the local con-, ditions arising in the upper abdomen.

Malignant disease of the gall bladder, as is well known, may be caused by the presence of stones which, of themselves, give rise to very few objective, or even subjective, symptoms. Surgeons wonder in these days, after their cholecystectomies, what the gall bladder is for, so much relief is obtained by its removal, and so little ill-effect is produced thereby. Cholecystitis has widespread effects where the disease extends upward, perhaps, into the hepatic ducts, gall ducts, or by continuity, through the common ducts into the pancreatic ducts, producing a chronic interstitial pancreatitis, and even without this, adhesions, more or less firm, between the gall bladder, the duodenum, the stomach, the colon, ascending and transverse, extending down not infrequently often involve the cecum and the appendix. Two cases operated upon recently showed simultaneous, or consecutive, one can not say which, involvement of the appendix with cholecystitis, and it is quite possible that some of the unsatisfactory results follow

ing operations for chronic appendicitis were due to the fact that we had not extended our exploration far enough up along the cecum and the colon to explore the gall bladder, and relieve conditions there. In both the cases just referred to the prominent symptoms were toward the right hypochondriac region, and the operations undertaken in order to relieve suspected conditions there, whether stones or simple cholecystitis, was not definitely determined beforehand. In both, chronic inflammation of the gall bladder was revealed, without stones, but firm adhesions of the colon to the gall bladder, contracted and thickened gall bladders, and the inflammation was traced down along the ascending colon until the appendix was found involved in a series of adhesions, which justified the removal in both instances.

We should operate to relieve conditions that threaten trouble, without waiting for the actual trouble to begin. Comparison between gall-bladder disease and appendicitis has been made, and the conditions are sufficiently alike to allow us to treat them in the same way. The comparatively less danger of acute suppurative cholecystitis, as compared with acute suppurative appendicitis, is due, of course, to the fact of the more protected situation of the gall bladder, as compared with the appendix, the appendix lying almost free in the abdominal cavity, and when it becomes the seat of acute suppurative inflammation from the colon bacillus, a general peritonitis is likely to occur, unless the omentum comes down and protects, as, fortunately, it frequently does. The gall bladder is enclosed, has thicker walls, it lies in contact with other organs in the vicinity, adhesions form quickly, protecting the general cavity, and while we do not have general peritonitis following suppurative cholecystitis as frequently as we do suppurative appendicitis, it lays the foundation for many local conditions that require interference later.

One has only to look over the statistics given in Mayo's recent articles on this subject to appreciate the great variety of conditions which may arise, calling for the highest surgical skill for their relief, and yet which might have been prevented by a more timely interference. My object

in saying these few words is to urge upon the profession, both medical and surgical, to be alert for early symptoms of gallbladder disease, and take the steps necessary to prevent its wider development. 87 Elm Street.

[Written for the MEDICAL BRIEF.] A Frequent Mistake in Extra-Uterine Pregnancy.

BY RALPH WALDO, M. D., Professor of Diseases of Women in the New York Post-Graduate Medical School and Hospital; Gynecologist to Lebanon Hospital; Gynecologist to Post-Graduate Hospital; Fellow of the Academy of Medicine; Member of N. Y. State Medical, County Medical, Obstetrical and Lenox Medical and Surgical Societies; State and County Medical Associations, etc., etc. New York City.

This subject is best illustrated by a description of two patients whom I have recently operated upon. The first, Mrs. B., Russian, thirty-six years old, married for twelve years. Menstruated first at thirteen, every four weeks, five or six days at a time; complained of pain during entire flow. Has given birth to three children; first, eleven years ago; last, two years ago. Labors normal. No miscarriages. About seventeen days before presenting herself at the clinic she had an attack of cramping pain in the abdomen, which lasted about six hours. During this attack she vomited twice. Was treated by her physician and improved. Five days later she had another attack of pain in the abdomen, and some diarrhea. Her family physician again prescribed for her, and she again improved. Since this first attack she complained of general weakness, loss of appetite, general indisposition, and claimed she was unable to attend to her household duties. Shortly after the second attack she was curetted. First presented herself to the clinic October 6, 1904. Stated that five weeks ago she had last menstruated, but for one day only, which was the first time that she had ever menstruated so short a time. Her temperature at that time was 994 F. General appearance was fair. She complained of pain and tenderness in the lower portion of the abdomen. Tumor about two inches in diameter was

found to the right of the uterus. This was fairly sensitive and apparently slightly fluctuating. A diagnosis of extrauterine pregnancy was made, and on October 10, 1904, the abdomen was opened, and it was found to contain a small amount of fluid blood, and the tube was found the seat of an ectopic gestation, which was removed. The abdominal wound was closed, and the patient made an uneventful recovery.

Case 2.-Miss S., twenty-three years of age, single, presented herself at Lebanon Hospital, October 17, 1904, stated that she had never had any illness previous to the present one, which dates from September 11, when her menses appeared one week after the usual time. On careful questioning she stated that she thought she had been pregnant, and had taken medicine which she believed was the cause of the appearance of the menses. She stated that there had been no mechanical interference. The flow continued, more or less irregularly, until she entered the hospital. Shortly after it commenced she noticed a few small pieces of material in the blood discharged, and the physician she consulted curetted her, believing that she had had an incomplete abortion. Following curettage, she complained of slight pain in the left side, and had quite a good deal of fever. On examination there were decided evidences of inflammatory disease, involving the pelvic structures, and it was believed that she had pyosalpinx on the left side, and very probably an extra-uterine pregnancy on the right. In spite of the fact that she had never had severe fever; temperature was about one hundred, and her general appearance fair.

October 20, the abdomen was opened, and the above diagnosis confirmed. The infection was so severe and the clots in the ectopic so fetid that the abdomen was drained. She made an uneventful recovery.

Last winter it was my fortune to operate on seven extra-uterine pregnancies in five weeks, and I believe that was quite largely due to the fact that at Lebanon Hospital sepsis following abortion and pregnancy at term are admitted. Several of these cases of extra-uterine pregnancy were believed to be sepsis following

abortions, as will be noted was the case in the two histories just cited. This diagnosis is justified, when superficial examination of the symptoms is made. For in both cases you have symptoms of early pregnancy. In both cases you have a discharge, frequently continued some time; usually in extra-uterine pregnancy the escape of blood is not excessive, but that is not always the case. In one instance I found it necessary to tampon the uterine cavity to prevent the patient from bleeding to death. In both extra-uterine pregnancy and sepsis following early abortion, you have a slight rise of temperature, and you have in both instances the escape of more or less solid material and clots, which many times are not very carefully examined. Of course, in an extra-uterine case you would never find a fetus.

In my experience one of the most important symptoms of extra-uterine pregnancy is a in slight irregularity the menstrual flow, and when the flow comes it is of very short duration at first. Another important one in quite a large percentage of cases is cramp-like pain, which may be very intense in one side or the other, associated with fainting, or a condition very closely approaching it; at the same time there is usually a discharge of blood from the vagina. The patient usually recovers from this attack, and in from five to ten days has another very similar one, again recovers, and again the attack returns. These attacks become more and more severe as time goes on, and if allowed to persist will frequently cause the patient her life. With these attacks there is a marked blanching of the face, which is usually the result of the abdominal shock, due to the escape of blood into the peritoneal cavity. In more rare instances, and always late in the disease this blanching is also due to loss of blood.

It is needless for me to give a description of a classic case of extra-uterine pregnancy, as my idea is simply to throw out a few hints to assist in making a differentiation between extra-uterine pregnancy and early abortion.

59 West Fifty-Fourth Street.

[Written for the MEDICAL BRIEF.] Uterine Polypi.

BY H. HUGH HELBING, M. D., Professor of Gynecology and Abdominal Surgery in the American Medical College. St. Louis, Mo.

These growths are of two general classes, determined pathologically. They are either glandular or fibrous. The former, also, denominated mucous polyps, usually develope from the cervix, originally, and are due to a proliferation of the cervical glands. The latter, as a rule, originate as sub-mucous fibroids in the fundus, or body, of the uterus, and are gradually forced downward during their development. It is of this form of polypus to which we wish to direct your attention.

The causes of fibroid polypi are somewhat obscure. They may be due to some irritation of the uterine wall. Negroes are more apt to be afflicted with fibroids, and age, also, is a predisposing cause, for they usually appear about the time the patient is approaching the menopause. The reason for this is the fact that they are slow in growth, requiring eighteen to twenty years before they attain sufficient size to cause disagreeable symptoms.

A uterine polypus is manifested by two leading symptoms, pain and hemorrhage. The former is produced by the contractions of the uterus in its efforts to expel the tumor. The latter are due to a thinning of the lining membrane, and a consequent exposure of the uterine vessels. Besides menorrhagia, metrorrhagia and dysmenorrhea, the patient may suffer from pressure symptoms, due to encroachment on the bladder, or rectum, so the patient may complain of pain in the sacral region, reflex headache, etc. She may have lost so much blood as to exsanguinate her, leaving her exhausted and anemic. The diagnosis should be made by bi-manual palpation and inspection. the growth occupies the uterine cavity and is small, it will be difficult to determine whether the wrong be polypi or endometritis; it may be impossible, unless we can introduce the finger high enough in the cervical canal, to feel the growth. If it is sufficiently large, say the

If

size of a walnut, we might with a sound determine the diagnosis by outlining the polypus and its pedicle. With the sound we find an increased depth of the uterine cavity.

Fortunately, by the time the growth reaches sufficient size to occasion trouble to the patient, the polypus presents in the cervical canal so that we may discern it on inspection, or it may be seen by dilating the canal. According to my experience there is no relationship between the size of the growth and the amount of hemorrhage it will produce. The very smallest, perhaps only the size of a pea, may cause as much hemorrhage as one the size of an orange.

When the tumor is attached to the cervix and occupies the vaginal canal, the diagnosis is simple.

Among the complications that may be encountered is, first, pregnancy. While, as a rule, the growths produce sterility, still an exception occurs once in a while. The patient seldom carries to full term, however, but in any case delivery is often complicated, and the patient's life is endangered.

Gangrene may supervene if the pedicle is constricted in any way, such as by torsion, or after the tumor is expelled, the cervix contracting down around the pedicle and shutting off the circulation.

Sepsis may occur, either during the process of removal or following gangrene of the growth.

The treatment will be one of three forms, either medicinal, electric, or surgical.

Along the line of medicinal measures will be such as will assist Nature. If the growth is up in the uterine cavity we may give ergot, or ustilago maydis, to produce uterine contractions, and force it out. If hemorrhage is severe we may pack the uterine cavity with iodoform gauze, which will stimulate contractions. If anemia exist, administer soluble citrate of iron, or the peptomanganate; also, any other medicines that may be indicated.

Electric treatment is more of a palliative nature than curative, looking to time of the menopause, when we hope the growths will begin to atrophy and hemorrhage cease. However, this rule is more ap

plicable to other forms of fibro-myoma than to the sub-mucous, or to polypi. Suffice it to say that galvanism, positive pole active, and the use of ten to twenty milliamperes may be used for checking the hemorrhage. The only curative measure that can be instituted with any degree of success is surgical in its nature.

The reason for presenting this subject to the readers of the BRIEF is the fact that I recently secured one of the largest polypi that I have ever seen on record, and a picture of which I herewith present.

The specimen measures twenty-two centimeters (nine inches) long, and eleven centimeters (four and one-half inches) in diameter. The longest diameter of the pedicle, which was ovoid in shape, was two centimeters. It was attached to the left lateral border of the external os.

The patient, who was thirty years of age, was being treated by Dr. J. L. Ingram, who had observed it protruding from the vulva the day previous to its expulsion from the vaginal canal. At first appearance we thought it might be an inverted uterus, but upon closer examination we located the cervix and pedicle of the growth. It had evidently been

expelled from the uterine cavity during a period of two or three days, all of which time there were hard labor pains. We merely ligated the pedicle, after transfixing and severed it. The patient recovered promptly. Examination with the microscope of sections of the growth showed it to be a fibroid, and non-malignant. Other methods of severing the pedicle are by torsion, or with the ecraseur, usually adopted where the growth is attached high up in the wall of the cervix, or body of the uterus.

4235 West Belle Place.

[Written for the MEDICAL BRIEF.]

A Contribution to the Pathology of Alcoholic Neuritis.

BY HARLOW BROOKS, M. D.,

Assistant Professor of Pathology in the University and Bellevue Hospital Medical College; Curator to Bellevue Hospital (4th Div.); Pathologist to the Montefiore Hospital for Chronic Diseases; Fellow of the American Association Military Surgeons; Member of the Neurological Society; Pathological Society; Fellow of the Academy of Medicine; etc.; etc. New York City.

James Jackson, of Boston, in his paper on "A Peculiar Disease Resulting from the Use of Ardent Spirits," published in 1822, first described alcoholic neuritis. Magnus Huss, in 1852, in his classical work on chronic alcoholism, described the condition much more fully, and ascribed the symptoms of this peculiar type of paralysis to lesions of the central nervous organs. This theory held for a considerable length of time, until investigations of the peripheral nerves established the presence of lesions here, the first of these cases being published by Dumesnil. Numerous observations by subsequent investigators showed the constancy of these peripheral changes, and now the conception of the disease became that the peripheral lesions were the basis of the paralysis, an idea that is still generally advanced in nearly all the text-books, most of which still classify alcoholic neuritis as a primary condition of the peripheral nerves, and generally occurring without lesions of the central nervous organs, except such secondary ganglionic alterations as necessarily follow degeneration and

death of the peripheral portion of the nerve fibers.

According to this idea, the disease, as regards its pathology, is generally subdivided under two classifications, namely, a parenchymatous neuritis, in which the earliest or chief alterations are in the nerve fibril, that is, degeneration of the axis cylinder process and interstitial type in which hyperplasia of the endoneurium' and perineurim are primary; pressure atrophy following in the axis cylinder process. It is, also, generally stated that these changes are found independent of any alterations in the brain and cord; in other words, that the condition is purely a peripheral one, and that it is never, or rarely, accompanied by degenerations in the spinal cord and brain.

The great impetus given to research concerning changes in the ganglion cell following the announcement of the "Neurone Theory," and the important contributions of Neisl, by means of which it was made possible to study with at least some degree of accuracy the finer and earlier changes in the ganglion cell, produced at once a large number of studies concerning the alterations in the nerve cells in alcoholism. Van Giesen, Ewing, Berkeley, and many others, showed definitely that alcoholism produces changes in the ganglion cells of the cerebral cortex, of the spinal cord and spinal ganglia, which, while of no definite, or specific type, were such as to seriously interfere with the proper function of those cells, and which, if continued, must eventuate in death, or such serious crippling that axis cylinder degeneration must follow.

Now, accepting this incontrovertible evidence, we are forced to the conclusion that either the neurone theory is wholly erroneous, or that those alterations in the ganglion cells, in cases of chronic alcoholism, must cause degenerations of the axis cylinder processes in the tracts of the brain, spinal cord and peripheral

nerves.

With the view of substantiating or overthrowing this theory Lambert and I have been conducting a series of investigations on; first, cases of typical alcoholic neuritis, occurring, as the disease most frequently does, in young women; and, second, a series of consecutive cases of