The case is noted of an old gentleman who had suffered from attacks of gall-stone colic, from ten to twenty times a year, for twelve years, and who, during the next four years of treatment with phosphate of sodium, did not have a single attack. In individual cases sodium phosphate, sodium salicylate, salol, and beef-gall can be alternated, each one being given for a time and then substituted by another. Physical exercise plays an important part in the treatment. Horseback riding is regarded as a good form of exercise, and bicycle riding is also to be recommended in this connection. Exercise of whatever sort must stop short of fatigue. The best diet in biliary lithiasis will be a mixed one, in which meats and fats enter somewhat largely, and in which there is no excess of sugars and starches.

Charles McBurney states that the chronic form of bile-stone usually comes under the surgeon's care after the symptoms have existed for a long time; there is clearly a chronic obstruction of the duct, and the symptoms indicate that there is no particular change going on excepting such as is disadvantageous to the patient. Those cases should be operated on as soon as that conclusion has been reached. The acute cases, in which the obstruction has come on recently, deserve much consideration. In such a case there is always doubt whether the condition is the beginning of a chronic obstruction or whether the stone is making its way downward and will finally escape. Perhaps the best and safest guide in these cases is the condition of the patient. Frequent attacks of pain indicate efforts on the part of the duct to push the stone along, and, if the patient is not really made ill by them, it may be well to wait. If, on the other hand, there is a fever with increasing tenderness, and the patient is really ill, an operation is advisable. The best way to avoid the difficult gall-stone operation is to operate on those patients who have gall-stones in the gall-bladder, with attacks of colic from which they usually recover without operation. It is much better to get rid of the stones which are in the bladder and which furnish the material for these difficult obstructions later on. An operation for the removal of gall-stones from the bladder is simple, and patients usually stand it very well.

Clinton Cushing thinks that if the gall-bladder is so seriously diseased as to warrant a surgical operation for its relief, it is better practice to remove it in toto than to leave it as a place for further accumulation of gall-stones, or as a point for the setting up of new inflammations.

W. L. Carr regards the predisposition to gout and rheumatic disorders as largely concerned in the production of gall-stones. If the bacterium coli commune is a cause, it is on account of its producing a catarrhal condition of the intestinal tract. He relieves the pain of biliary colic by morphine and atropine, to which large draughts of water may be added. For the diet, in preventive treatment, foods slow of digestion and those which are especially rich in fats and sugars are to be strictly forbidden. Chloroform, ether, and turpentine have really little action in dissolving the stones. Sweet oil is a valuable adjunct. Salicylate of sodium, chlorate of sodium, succinate of sodium, and the succinate of iron are useful in stimulating the flow of bile. Massage of the abdomen, with gentle manipulations of the region of the gall-bladder, is recommended. Surgical means alone, however, will afford relief in impaction.

In the treatment of gall-stones during the paroxysms of colic, J. W. Irwin says the best way to relieve the acute pain is to use morphine and atropine hypodermically, and to put the patient in a warm bath. Between the attacks of biliary colic, a drachm of ether to an ounce of whiskey, given four times a day, is excellent. The mineral waters of Carlsbad are useful, but equally as effective are the waters of Saratoga Springs. Vichy and geyser water are especially useful. When the foregoing methods fail, the surgeon's knife carefully used will effect permanent results. Cholecystotomy appears to have been the least dangerous to life of all abdominal operations, and it is the best for the removal of gall-stones. Death rarely follows operation.

W. F. Boggess does not believe that every case of biliary colic means gall-stones. It is often due to an inspissated condition of the bile; there are often catarrhal conditions of the gall-ducts in which inspissation of the bile takes place, and which phosphate of soda will relieve. The majority of cases that get well under so-called medical treatment are simply cases of this character. He does not believe it is possible to dissolve gall-stones by any form of medication by the mouth, and the only hope of permanent relief is by surgical operation when the stones do not work off through the natural channels.

In the treatment of cholelithiasis F. C. Ferguson regards mere palliative remedies, whether they be medical or surgical, as pernicious,-mere makeshifts,-often leading to a fatal issue. However, in first attacks of hepatic colic tentative treatment is

allowable. The attack may pass away in a few days and the patient apparently recover. But he should be warned that sooner or later the attack will, in all probability, recur, and a surgical operation may be necessary to save his life. But in acute attacks attended with jaundice and lasting longer than from ten days to two weeks, and in which there are no signs of improvement, operation is indicated. In all acute cases, unattended with jaundice, lasting for a week or more without improvement, operation is unmistakably indicated. In all chronic cases—namely, cases in which there has been a recurrence from time to time of hepatic colic, whether there is or is not a coincident jaundice-operation is indicated. Then there is another class of cases, chronic in nature, that drag their slow length along for months, sometimes for years, in which the distinctive symptoms of gall-stones having been merged into constipation, chronic indigestion, anemia, soreness, and sometimess excessive tenderness in the epigastric region. Jaundice, if present at all, is very slight. The gall-bladder in such cases is liable to undergo cancerous degeneration, and should be operated upon without delay.

In operation for gall-stones the vertical incision at the outer border of the rectus is preferred by C. A. Hamann. If the gallbladder is distended with fluid one must aspirate. Should pus be present it will be best to suture the gall-bladder, unopened, to the abdominal wall, and, after a couple of days, open it and remove the stones. If pus is not present it is best to open the gall-bladder at once-the surrounding parts being well protected with gauze—and remove the stones. After this the ducts should be explored by one or two fingers in the foramen of Winslow and the thumb in front. A stone in the cystic duct may be forced upward, or it may be crushed with the fingers or padded forceps. A large stone in the common duct may be cut down upon, or the duodenum may be opened and the stone gotten at from below. If the duct is opened sutures are then to be inserted. In this procedure Halsted's aluminum hammer inserted into the opening will aid materially in the manipulations. After the stones have been removed from the gall-bladder, and while the deeper parts are being explored, the cavity should be partly filled with sterile gauze to prevent bile from escaping into the peritoneal cavity. Finally, in the majority of cases the gall-bladder should be stitched to the abdominal wall. If a

stone, for some reason, cannot be removed from the common duct, and must be left, it is proper to do a cholecystenterostomy, using the Murphy button to attach the gall-bladder to the small intestine.

GYNECOLOGY AND ABDOMINAL SURGERY.

Under charge of SOPHIE B. KOBICKE, M. D., Adjunct to Chair of Gynecology and Abdominal Surgery, College of Physi cians and Surgeons of San Francisco.

Enteroptosis in Relation to Diseases of Women.-The relation of enteroptosis (Glénard's disease) to diseases of women is at present receiving marked attention. There is much of interest to gynecologists, therefore, in a synopsis made by New York Medical Journal, of a paper by Dr. W. F. Hamilton, of Montreal. He says that, notwithstanding the conflicting views concerning the classification of cases under this head, it may be accepted as safe teaching, at least for the present, that enteroptosis may exist without subjective symptoms. The enteroptosis of Glénard is usually, however, associated with the most pronounced subjective signs, chiefly of a neurasthenic type. In those cases where a pendulous abdomen is present, the nervous features are less pronounced than in the subjects with flattened abdomen. Typical enteroptosis may result from inflammatory processes in the abdomen. Any of the abdominal organs may be displaced in this disease. Most frequently, however, the colon and small intestines, the stomach, the right kidney, and the liver are found in altered relations. The condition is due to an atony of the nervous system with a corresponding relaxation of the muscular structures of the body. Its predisposing causes are heredity, chronic disease, unhealthful methods of living, and the wearing of corsets. The disease is often to be looked upon as a constitutional ailment. The diagnosis of enteroptosis is comparatively easy. The epigastrium is hollow; the two lower quadrants of the abdomen, even with the patient in a reclining position, are often quite prominent. It is most important to determine the lesser curvature of the stomach and its relation to the greater curvature. Where the lesser curvature can be demonstrated, some degree of displacement exists; the amount of displacement is to be measured by the relation of the lesser curvature to the umbilicus. Palpation usually reveals movable kidney, and the liver when displaced

is usually more prominent in the epigastrium, and may be easily rotated on its long axis. In the diagnosis of this affection Glénard laid special stress on a test which was applied by the examiner standing behind the patient, also in the erect position, and laying both hands flatly over the lower zone of the abdomen. The firm but gentle pressure is made upward. In the great majority of cases this affords considerable relief to the distressing pain which is felt in the epigastrium and which is one of the patient's chief complaints.-Am. Journ. of Surgery and Gynecology.

A New Method of Transplantation of the Ureters. —A new method of transplantation of the ureters has been devised by Dr. F. H. Martin, Professor of Gynecology in the Chicago Post-Graduate Medical School, designed for dealing with the ureters in cases where extirpation of the urinary bladder becomes necessary. From experiments on dogs he has found that the rectum makes a fairly good receptacle for the urine, but that implantation of the ureters, as has been heretofore proposed, results in infection of the kidney, and subsequent death from nephritis. He has, therefore, attempted to obviate this evil, and has succeeded by so placing the ureters that they will empty in the direction of the long diameter of the rectum, in the walls of which they are buried longitudinally for a distance of an inch or more. By so doing, in the act of defecation, the fecal mass will squeeze the calibers of the ureters closed by its pressure on the mucous membrane, and the pressure being exerted from above downwards in the direction of the outward flow of the urine, will empty the ureter by a milking process.— Am. Journ. of Surgery and Gynecology.

Kraurosis Vulva.-J. M. Baldy and H. F. Williams describe this condition as being either unilateral or circumscribed, but usually the tissues of the labia majora, nymphæ, the area about the clitoris and urinary meatus, all become more or less involved. As the disease advances the labia minora gradually disappear, fusing with the labia majora, and the skin becomes drawn and shiny over the sunken clitoris, which apparently retracts behind the skin and is indicated by a small depression. Underlying vessels are frequently seen through the epidermis, and cracks appear. A sensation of drawing and shrinking of the vulva is usually experienced, and the vulval orifice gradually becomes contracted until it will hardly admit the little finger. At this