that the accommodation of the ducts in the liver is inadequate, jaundice is always present. In many cases in which these remain patent no jaundice is observed. If a suppurative process is present in the gall-bladder or ducts, jaundice is likely to appear, since the destruction of the epithelial lining permits absorption. The quick disappearance of jaundice indicates temporary obstruction of the common duct.

In this case I could outline the gall-bladder, which was enlarged and tense. Patient complained of soreness upon pressure. In many cases it is impossible to outline a tumor. If the gall-bladder be distended or there be adhesions from local peritonitis a tumor can usually be palpated and percussion shows dullness. When the cystic duct has been obstructed for a long time I have found the gall-bladder distended with a strawcolored thin fluid. Some report that by auscultation they have heard the stones rubbing upon each other. I have never been able to do so. In cancer, while confined to the gall-ducts a tumor could not be felt.

To make diagnosis between a tumor formed by gall-stones in the gall-bladder with adhesions and cancer of the same structure might be

FIGURE 1.

impossible, even after a careful consideration of
the history, signs and symptoms. In one case
of a man extremely emaciated I could feel nod-
ules in the lower edge of the liver, due to
secondary involvement. In the last case of
cancer in which I made exploratory incision
the lower edge of the liver, although involved,
was perfectly smooth, the involvement being
by contiguity of surface from the gall-bladder.
The loss of flesh in cases of cancer in this
region is rapid, and yet in some nonmalignant
cases in which there have been repeated attacks
of biliary colic the loss of flesh is also marked.
The pain in cancer, although it may be inter-
mittent, is more persistent, and when far enough
advanced that tumor may be palpated, colic is
usually absent, When cancer starts in the gall-
bladder jaundice is a later symptom. I saw one
case in which the jaundice was slight up to two
months before death.

Vomiting is considered one of the most constant symptoms. In the case of MRS. B., upon whom I operated December 1, 1900, at Harper Hospital, and who had suffered well nigh constant distress in the region of the gall-bladder for four months, and who showed deep continuous jaundice with marked loss of flesh, the patient never vomited. Three large stones were found in the gall-bladder. The ducts were free.

When infection has entered traumatisms made by gall-stone the ducts may become closed by inflammation or by contracting adhesions, the gall-bladder becoming more and more distended until its purulent contents are emptied into the peritoneal cavity or some other viscus to which it has become adherent. In this way stones so large as to cause intestinal obstruction may pass; or, on the other hand, the gall-bladder may become small and contracted Abscess may form rapidly and the attendant perihepatic inflammation or local peritonitis cause tension of the muscles upon the right side of the abdomen with fever and disturbed heart

action, and a diagnosis of appendicitis be made; but usually a careful inquiry into the history of the case will determine which is the offending. organ. At a recent meeting of the Detroit Academy of Medicine, DocTOR HENEAGE GIBBES made the statement that primary leucocytosis depended upon the amount of adenoid tissue in or adjacent to the site of suppuration. If this be correct, examination of the blood would be an important factor in differential diagnosis, since there is a great amount of adenoid tissue in the appendix. In these cases of cholangitis with or without gall-stones, jaundice is usually an early symptom. Metastatic abscesses and pyemia may occur.

I wrote the above after my examination of MRS. F., May 1, and have not changed it, thinking the disclosure of operation would be more interesting. I expected to operate on the 7th, but her attack began with flat

ulency and the characteristic pain upon the morning of the 6th. She had suffered from soreness since my previous examination. I did not see her until evening, by which time the pain had become agonizing and the yellow of the urine was deepening. I operated at midnight at Harper Hospital. She has been losing flesh rapidly for the past three months, yet the depth of the adipose tissue upon the abdomen was several inches, necessitating a large incision. I found the gall-bladder distended and about twice the normal size. Fifty small gall-stones, many of them being of triangular shape and flat with sharp points resembling the tacks used by glaziers, were found in the gall-bladder, some of them completely blocking the cystic duct. The fluid in the gall-bladder was a light strawcolored mucus. Examination of one of the gall-stones showed that it was composed mainly of cholesterin, with some bile-pigment, some altered

epithelial cells and small masses of mucin, but with no separate nucleus and no bacilli. I examined the other duct carefully, passing a probe through into the common duct. They were free. It, therefore, contrary to my wish, confirmed the diagnosis made several days before. I say contrary to my wish, because I have made a number of mistakes in differential diagnosis between this condition and cancer, as well as in determining the location of calculi. I think a mistake in this case would more likely convey the true status of our power of accurate diagnosis in the varied conditions found in the region of the gall-bladder.

When the patient was ready for operation she requested that I investigate the pain farther down, pointing to the region of the appendix vermiformis. She said the pain there had been severe all the afternoon. Examination of blood taken at time of operation showed marked

leucocytosis and the presence of mononuclear lymphocytes in a greater proportion than normal. This change in the blood cannot be explained by the condition found in the right hypochondrium, but by what was found at McBurney's point. I brought the cecum into the wound and found a firm erectile appendix with no adhesions. When I made incision into it thread-worms, oxyuris vermicularis, began to crawl out. All that we examined were adult females. The photograph (Figure I) of the appendix, which was split longitudinally, shows the proximal end of its lumen to be irregularly dilated, looking like the condition that prevails when an enterolith is formed, but none were present. Many microscopic sections were made. These showed a condition of acute inflammation throughout. The lymphoid masses presented a ring of lymphocytes round the germinal centers which stained intensely while the cells in the

germinal centers were in an active state of karyokinesis. Pus in small quantities had formed. All the lymph paths extending from these nodes were full to distension with lymph corpuscles (Figure II), and could be traced to the outside of the circular muscle coat in places. Diapedesis was seen along the course of the small blood-vessels; in fact, there was evidence of intense inflammatory change throughout the entire organ. (Figures II and III).

To recapitulate, although many signs and symptoms usually present to enable the surgeon to make a diagnosis of cholelithiasis, yet the only positive sign, I believe to be the discovery of the gall-stone in the feces. When symptoms of disease affecting the biliary passages are persistent, exploratory incision should be made to complete the diagnosis and at the same time to give relief.

I am indebted to DOCTOR HENEAGE GIBBES for the microscopic and photographic work in connection with this paper.

A SYMPOSIUM ON GENITOURINARY DISEASES. ETIOLOGIC FACTORS IN GONORRHEA.*

BY THOMAS S. BURR, A. B., M. D., ANN ARBOR, MICHIGAN.

FIRST ASSISTANT IN SURGERY IN THE UNIVERSITY OF MICHIGAN.

PUBLISHED IN The Physician and Surgeon EXCLUSIVELY)

A KNOWLEDGE of the etiology of a disease is necessary to the physician if he is to select intelligently the means of intrenching his patient against it, or the proper weapons wherewith to combat it if prophylaxis fails. The etiology of a disease is the etiology not only of the affection per se, but also of the various complications and sequelæ usually incident to it. This is particularly true of the disease under discussion, as it is not the initial urethritis, but the insidious remote effects of gonorrhea which make it an object of dread.

In dealing with the etiology of gonorrhea, the majority of writers confine themselves to a discussion of the infecting agent, considering the bacterium the sine qua non of the condition. That the disease is due to bacterial infection is practically beyond dispute. The observations of NEISSER, instituted in 1879, and elaborated by scores of observers since that time, place this fact beyond cavil. Whether the gonococcus is a good bug gone astray, or one naturally and inherently depraved, is a question of no practical importance. The fact that it is found in those cases of urethritis which we call gonorrhea, and which run the wellknown obstinate and frequently unfortunate course, is sufficient to place it on the bacterial black list; while the fact that cases of urethritis in which the gonococcus is not found, progress to a speedy and complete recovery, seems very good evidence that the germ in question plays more than a minor role in the causation of the disease. Personally, I believe the gonococcus usually associated with other organisms to be the specific germ of gonorrhea. On this supposition the etiology of the disease is concerned with those agencies which make possible the entrance of the germ, facilitate its development, aid its migration to parts remote from the point of inoculation, and thus make possible the unfortunate train of complications and sequelæ which so often supervene. Agencies which produce a mixed infection are also to be considered.

*Read before the MICHIGAN STATE MEDICAL SOCIETY at its Battle Creek meeting

In discussing these points I shall limit my comments mainly to gonorrhea in the male. If gonorrhea in the male can be restricted the chief etiologic factor of the disease in the class of women whom we wish to protect will be correspondingly limited.

The male urethra is a narrow tube presenting five natural constrictions, and three dilatations. At either extremity of the membranous portion the urethra is surrounded by more or less unyielding tissue, the planes of the triangular ligament. It is lined for the most part by columnar epithelium, the fossa navicularis having a squamous covering for a few lines, and the transitional epithelium of the bladder being continued into the prostatic portion for a short distance. The fossa navicularis contains numerous small crypts, and one, the lacuna magna, of considerable size. The bulbous portion is studded with follicles, and presents the orifices of the ducts of Cowper's glands, the latter lying farther back in the membranous portion. In the membranous portion are also found the sinus pocularis, the ejaculatory ducts, and numerous follicular openings, and in the prostatic part are the tubules which convey the secretion of the prostate gland. The mouths of the urethral glands and ducts are directed toward the meatus, and if enlarged may engage the point of a bougie when instrumentation is attempted.

The germ entering the urethra finds ready lodgment in the epithelial structures, penetrates easily into the follicles, and if planted in the deeper urethra gains ready access to the glands of Cowper, the sinus pocularis, the ejaculatory ducts, epididymis and testicle, the prostatic structures, and if the last barrier is passed the way is opened to the bladder, ureters and kidneys. The gonorrheal pus accumulating in the expanded portions of the urethra is to a certain extent dammed back by the natural constrictions, and acts by its contact as a macerating and irritating agent. From these statements it will be seen that the anatomic conformation of the ure thra possesses points of etiologic interest. Another anatomic structure which predisposes to urethral infection is a redundant prepuce. Of undoubted importance in syphilitic invasion, I consider the existence of a long prepuce a very potent agent in the acquisition of gonorrhea. A good majority of patients presenting themselves to me for gonorrheal treatment have such a prepuce. It seems reasonable to suppose that the bacteria may become imprisoned beneath the foreskin, escape a hasty genital toilet after coition, and subsequently reach the urethra and develop. Certainly germs so imprisoned can initiate a severe phimosis, balanitis and balanoposthitis. In passing I may say that I think the Hebraic custom of circumcision is worthy of gentile adoption.

The rich blood supply of the urethra, the abundance of erectile tissue adjacent to it, a mucous lining peculiarly susceptible to irritation, render hyperemia of frequent and ready occurrence. This affords another condition most inviting to the gonococcus. A urethra that might ordinarily resist a gonorrheal invasion will succumb when irritated by a urine laden with the metabolic products of alcohol, or when gorged with blood as a result of venereal excesses. If, as is claimed, phagocytosis is interrupted in the presence of gonorrheal toxin, we have in this another etiologic factor.

Among etiologic factors I would include failure of those indulging in illicit intercourse to observe certain hygienic principles-certain measures of ordinary cleanliness. Sexual contact in the presence of gonorrheal infection does not necessarily mean that the individual so exposed will contract gonorrhea. The prompt removal of all infectious material from