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the other hand, it may be taken for granted that the average woman does constrict her thorax whether or not she will plead guilty to the charge of tight lacing. I have long ago ceased to credit any woman's statements in regard to her dress. I never found a woman who "laced.” “I don't wear my corsets tight” is the universal remark of the wasp-shaped females who come to us for advice. And yet in my frequent disrobing of patients for physical examination of the thorax, it is rare I find a lady whose waist does not show the print of the underclothing from tight pressure. Now, as regards the subject under consideration, it really makes no difference whether a woman wears corsets or not, though I always contend that unless they are worn tightly they make the waist look larger. The real question is, Is the waist constricted? and unless the clothing is suspended from the shoulders it is safe to affirm that it is.

But how can a little external pressure on the waist produce gallstones? Perhaps it would assist our understanding of the matter to review for a moment the anatomy of the parts involved.

The gall bladder, as you will remember, lies on the under surface of the liver immediately below the tenth costal cartilage. We can readily fix this location in mind as the tenth rib is the last to be attached anteriorly. It is from three to four inches long and will contain from an ounce to an ounce and one-half of fluid. The neck is narrow, curved upon itself like the italic small letter f, and at each extremity presents a well marked constriction.

Next comes the cystic duct, which passes obliquely downward to the left and unites with the hepatic duct to form the common duct of the liver. It is about one inch long with its internal mucous membrane arranged in a series of crescentic folds, to facilitate the entrance of bile into the gall bladder.

The hepatic duct does not immediately concern us at this time, though it may be well to remember that it is formed from the final uniting of all the minute biliary ducts which ramify throughout the entire substance of the liver.

By the junction of the cystic and hepatic ducts is formed the ductus communis choledochus, the most important of all. This is about the size of a goose quill and enters the duodenum a little below its centre. It is three inches in length, from which you can readily compute the distance from the gall bladder to the intestine as about four inches. The gall bladder itself is a strange little reservoir into which the bile is drawn up to be forced out and used during digestion.

We are all familiar with the grosser physical effects of tight lacing. The thorax which should expand from above downward becomes contracted instead, so that in some cases the false ribs almost meet. The liver may be actually forced upward or downward while in some instances from lateral pressure it becomes elongated in its vertical diameter. If the pressure is exerted by a narrow belt or tight cord, there may be left a deep furrow in the liver itself.

Now if all these changes can be produced upon the osseous walls of the thorax and comparatively hard substance of the liver, what must be the effect upon the calibre of the soft biliary ducts? Especially the cystic duct, which as we have shown is lined throughout its entire length with undulating folds? Indeed, as you stop to consider, the question of obstruction does not seem strange. The only thing that seems strange is how any bile can escape from the gall bladder at all.

But this is not all. Since man has assumed his present erect attitude by walking on two legs instead of four, the entire portal circulation has been impeded. The absence of valves in the large veins of the abdomen and thorax is in part responsible for this condition. If, now, to a feeble venous circulation mechanical pressure from tight clothing is added, we have at least a condition favorable to stagnation, which, as Sam Jones used to say, is the next thing to damnation, meaning, of course, in this instance a drawing up of the blood current and all of the hepatic secretions.

As a partial recompense for defective portal circulation nature has given to us the pump-like action of the respiratory muscles, by which the liver is alternately compressed and relaxed with every breath, but the effect of tight clothing spoils it all.

You will thus perceive that the construction of the waist impedes the portal circulation producing hepatic congestion and catarrh of the biliary ducts, this in turn favoring the formation of a perverted secretion which is retarded in its escape.

But it may be urged that the same pressure which causes the ducts to collapse also helps the gall bladder to expel its contents. Let us see:

We all know how easily the flow from a fountain syringe can be controlled by slight pressure upon the escape pipe. The amount of Auid in this case is several pounds, and the height of the column of course increases the pressure; what then must be the effect of a like pressure upon the hepatic ducts in which the aid of gravity to the escape of bile is almost entirely wanting? I have often experimented

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with a Politzer's bag and know that with the thumb and finger alone one can easily prevent the escape of air from the bag regardless of the amount of pressure exerted

upon

it. I think I have said enough to indicate that mechanical pressure from waistbands is quite sufficient to retard the portal circulation, diminish the calibre of the hepatic ducts and dam up the bile in the gall bladder. If this is true, unless the bile is different from any other fluid we know, disintegration is sure to follow, the biliary salts become precipitated and gallstones are the result. Of course there are other etiological factors. The lack of sufficient fluids in the system is perhaps the most prominent. Few people drink as much water as they need and this is especially true of women. All these things must be taken into consideration, and yet I believe that the excess of gallstones in the female is largely due to her mode of dress.

Dr. G. O. Welch, physician in charge of the Insane Hospital at Fergus Falls, Minn., says: “In 1,382 men and 675 women admitted to this hospital I can only recall two or three cases in which gallstones have been found. Over 70 per cent. of our patients are Scandinavians and the majority from the farming districts, therefore the women are not given to tight lacing."

Most authorities attribute the great frequency of gallstones in the female to her sedentary habits and quote in proof that prisoners (who by the way, are usually males) confined in cells are especially subject to them. I do not doubt that sedentary habits are an element in their production, but there surely must be other quite as important factors in the case. The use of alcoholic stimulants and excessive indulgence at the table, both of which obtain more frequently in the male, tend to produce this condition, and some believe there is a direct connection between gallstones, lithemia, asthma and gout. Anything that tends to produce hepatic congestion favors the formation of gallstones and by so much as man abuses his stomach more than woman are his dangers from gallstones increased.

The immediate results of a sedentary life I believe have been over-estimated. Dr. George S. Adams, superintendent of the Westborough Insane Hospital, says: “I have never known but one case of gallstone colic among our thirty-seven hundred patients.” Surely if being “shut in” would produce a condition of that kind, the Westborough Hospital ought to show a larger record.

Regarding the diagnosis of gallstones I will say that the stone itself is the only positive evidence, and the best way to find them is to break up the entire stool and wash it through a sieve. There is no use in looking for them at all unless it is done thoroughly. The stone will not float when it first escapes from the bowel, and the color is usually almost identical with the stool itself.

The attack of colic is most likely to come on soon after eating, due to the normal increase of the flow of bile at that time, hence it is apt, if slight, to be mistaken for indigestion. It may also be produced by any unusual exertion in stooping or reaching, which causes the stone to enter the cystic duct. A thickening of the bile from catarrhal inflammation may give rise to all the symptoms of an attack.

Jaundice in itself is no evidence of gallstones. Often the most severe cases show none whatever. If the stone has not passed far enough to obstruct the hepatic or common duct, there is no interference with the escape of bile from the liver. The gall bladder may be completely obliterated and yet no jaundice be present.

Regarding treatment I will only say a word. There is no doubt but the "ounce of prevention" consists in drinking freely of water, the removal of all mechanical restraint and the taking of abundant physical exercise.

Water in itself is the great solvent for every toxic ptomaine and excrementitious salt. Keep the fluids of the body free and there will be no vexatious concretions to be gotten rid of.

In my limited experience in the treatment of gallstones I have run the gamut of olive oil, pepsissewatra and Carlsbad salts. I have even used Durandé's remedy of oil of turpentine and ether, though not in his original dose. The recipe I followed was taken from Burnett's book and reads as follows: R.

Sulp. Ether 3 ii.

Oil Terebinth 3j.
M.
Sig. 10 drops in a cupfull of water three times a day.

China of course has been given a trial though I doubt very much if it ever merited the reputation it once had. It is a significant fact that the only case of gallstones reported by one of my correspondents had previously been under the professional charge of Dr. David Thayer for twenty years,

Perhaps the remedies I rely on most are chelidonium, bryonia and nux vomica. In the Transactions of the American Institute for 1895 Dr. Nancy T. Williams gives some very interesting experience with ipecac in this disease.

It is a well-known fact that ether will dissolve the cholesterin

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of the bile, which makes up the bulk of most gallstones, and my brother, Dr. N. W. Rand, of Monson, has seriously contemplated injecting the gall bladder with pure ether and thus dissolve the stones in situ. The expedient seems to me worthy of experimental investigation upon animals to find out what the effect of the injection would be. If the remedy itself will do no harm, there is no reason why gallstones may not be gotten rid of without the use of the knife.

For the attack itself I rely upon heat stimulants and the hypodermatic syringe. I do not believe any remedy administered by the stomach will produce the desired effect. I often apply chloroform upon cloths wrung out in hot water, which will surely change the sensations of the patient and perhaps give temporary relief.

In the preparation of this paper I have been surprised at the very small number of cases some physicians of large experience report and in other instances at the very large reports other physicians have rendered with not a single stone to show for them.

The experience of Dr. T. E. Sanger, of Littleton, N. H., is quite unique. Out of eight cases reported by him, all confirmed by calculi, seven were men. Of the remaining patient he thus writes: “My only case of gallstones in the female was a large fat woman who never wore corsets. The stone passed measured 11 inches in length. The diameter of the larger end was I 1-32 inches and of the smaller end 9-16 inch. It took three days to be delivered. Patient has never had a return of the colic."

The surgical treatment of gallstones which is said to have been first suggested by Dr. Handfield Jones and later put into practical execution by Dr. Marion Sims, is now after twenty years' trial the most satisfactory treament for inveterate cases, and in this connection the observations of Dr. F. P. Batchelder as surgical assistant to Dr. Horace Packard will be of especial interest: Out of twenty cases actually operated upon by Dr. Packard nineteen were women, and the only man reported was an "alcoholic wreck.” Were all my reports of like character there would be no need to assert that tight clothing and alcohol were a frequent cause of gallstones.

To the bulk of physicians, however, therapeutic measures are most practical, and right here I am sure you will all be interested in a brief report from that well-known physician, Dr. T. G. Comstock, of St. Louis:

"In treating gallstones I give freely of olive oil, drench the patient with hot water internally, and externally use baths and fomen

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