pregnancy conduces to gall stones, as do also abdominal tumors, corsets, the sedentary habits of women, and the trashy food that many of them live upon conduces to gall stones. It has been shown that if bile is kept for six weeks without agitating or shaking it, that its reaction changes to acid and a deposit will form; cholesterin will be thrown down. If the diaphragm can not be moved freely up and down, as it can not be when there is a large abdominal tumor or pregnancy, or when stays compress the waist, it is easy to suppose that stasis of the bile might occur, and that it might form the startingpoint of gall stones.

The first symptom of gall-stone colic is usually pain at the pit of the stomach, which in some instances extends around the waist; it may run up to the right shoulder, oftentimes down into the right iliac fossa, sometimes in the back, and sometimes it is most severe just beneath the heart. It may form a girdle or sense of constriction around the waist; cold perspiration breaks out over the patient, owing to the intense pain; a waxy pallor comes on, which is followed by reaction in a few hours, fever running up to 103-4 or 105° F., depending largely upon the idiosyncrasy of the patient. We may find the temperature to reach 105° F. in a bad attack of gall-stone colic. Every evidence of approaching death is present. There is often a deep-down boring pain in the epigastrium, a little to the right. If, in addition, we find jaundice coming on within a few hours from the beginning of the attack, we can say that it is due to occlusion of the bile ducts. If we find an enlarged gall-bladder, there must be something to cause it, and we may infer that the ducts are occluded, and if it be the first, second, or third attack, it is most likely to be caused by a stone. We may have distension of the gall-bladder with mucus, perhaps some muco-pus, not bile, because the bladder is not often distended by bile, it being only the receptacle for the overflow of bile; when it can not get out of the common duct it dams up and fills the bladder.

As to the medical treatment of this disorder, I have found on many occasions great relief to follow the hypodermatic use of morphine. I do not know anything better to give the patient for the relief of pain. In some cases where morphine did not seem to be satisfactory I have given a drachm of chloroform by the mouth, and have repeated this dose every three hours until sufficient relief was obtained. I have found that opening the bowels thoroughly by giving five grains each of calomel and rhubarb, and this followed in five

hours by the administration of a saline, has had a salutary effect upon the inflammatory condition. I have found between attacks it is well to keep the bowels freely open, and a good remedy for this is phosphate of soda. I have used succinate of soda, and it seemed to have good effect, not in dissolving the gall stones, but probably in preventing the formation of others. After administering it for a month the attacks of gall-stone colic that followed it were not so severe as those which occurred previously. I am led to administer this drug perhaps oftener than any other between attacks, but have not been so fortunate as Tyson, who claims that he has never seen an attack after its administration. I have seen repeated attacks after using this remedy. I have also administered large doses of olive oil, the old domestic remedy, not because I thought it was a specific, but because I often found it useful. In many cases I have seen quantities of gall stones pass, and have shown before this society two large ones following its administration. I am satisfied that the administration of olive oil has been followed by good results in many instances. I have also used Carlsbad water, have sent patients to Carlsbad Springs, and have treated them at home. I have sent them to the various springs about the country, have sent them to high altitudes and to low ones, and attacks have occurred just the same as if they had remained at home. Many of these cases can not be relieved by any medication, hence the surgeon's knife must be called into requisition. But I want to say that not every case of gall stones requires the use of the surgeon's knife. I believe that therapeutic measures will relieve four fifths of the cases.

Dr. Geo. W. Griffiths: I think it is always advisable, where gall stones are suspected, to strain the excreta through mosquito netting and search for stones in this way.

There is great danger of the patient becoming addicted to morphine when this drug is used under any circumstances; therefore, I would use chloroform and warm baths in preference.

Dr. W. H. Wathen: The paper very ably presented the subject as we understand it. The treatment of gall stones is certainly never medical, it is surgical or nothing. The treatment, however, of cholangitis or cholecystitis associated with gall stones may be at times medical, and these cases may be greatly relieved by administration of the various remedies suggested, and the patient may suffer much less after the use of these remedies. Those that cause pain, and where inflammation has developed, may be temporarily relieved and some permanently relieved of the inflammation by the use of medicine, but gall

stones are never dissolved and gall stones are never taken out of the gall-bladder by any form of medication. The only way that any kind of purgation can remove gall stones would be where they are located in the duct, practically in the walls of the bowel, and the medicine causing an intense peristalsis the gall stones are forced out.

Surgical treatment should only be applied where in the first place the stones are in the gall-bladder and inflammation and possibly suppuration has resulted, or there is obstruction to the cystic, hepatic, or the common duct. Gall-stone surgery, however, that has done the most good and that is the most scientific, is where we operate for the removal of stones from the common or hepatic duct, where we open the abdomen, incise the duct, remove the stone, and if possible suture the duct and restore our patient to a perfectly healthy condition. There are some cases where we can not suture the duct, for the reason that adhesions have formed binding the structures down so deep and so obscuring the duct that it can not be sutured. Then, fortunately, we can often drain, and the patient will get well by this drainage deep down to the opening in the duct, or we may keep the wound open by gauze packed carefully and closely around, above, and below. Many of these patients make complete recoveries, and finally the opening into the wall closes. If we know, however, the best technique of manipulating, we can often suture the duct down in its immediate proximity to the duodenum. In some cases we can use the little hammer devised by Keen, introducing it into the duct and thus bring it up to be sutured.

Dr. Peyton: I want to state that you may not only have a stone imbedded in the duct, but you may have it formed beneath the mucous membrane surface covering the duct, which may offer a suggestion to account for the theory mentioned in the paper as to the cause of the formation of gall stones, that they may not only be impacted in the duct, but they may be imbedded beneath the mucous membrane.

Dr. Carl Weidner: I beg to thank the gentlemen for their discussion of the paper. I think before a gall stone can get beneath the mucous membrane it must ulcerate through.

From the standpoiut of the general practitioner, as well as the surgeon, we have the right to consider a subject of this kind. I tried to bring before you in the paper the modern views as to the cause of gall stones, otherwise have told you nothing new. I will repeat, in spite of opposite opinions, that the majority of cases of gall stones belong to the domain of surgery. I am sorry that we have had to give

up these fields, but appendicitis and gall stones have slipped out of our hands into those of the surgeon.

The diagnosis in many cases is most difficult, particularly where we do not have jaundice, where we have pain which is not very characteristic, and where we see no stones pass. These cases sometimes resemble, more than any thing else, cases of simple gastralgia. No doubt many of us have seen cases of gall-stone colic of the character I have described, cases with stones in the bladder, with a stone occluding the neck of the bladder, possibly the cystic duct, where the gall bladder is not filled with bile, but with mucus or serum, where we get periodical attacks of pain due to nothing but temporary exacerbations of the inflammatory condition of the gall-bladder. These cases are hard to diagnosticate, because we rarely have jaundice and because we see no stones passing by the bowel.

As far as treatment is concerned, I passed over this hurriedly. I neglected even to mention chloroform. Certainly this is an excellent remedy, and I have given it in the treatment of gall stones frequently. So far as I know we have no solvent of gall stones within the body. When I was a student one of my teachers spoke highly of succinate of soda and stated that it seemed to have a solvent effect. I do not believe it acts any more as a solvent than other alkalies. Various remedies may be administered with the view of preventing the formation of stones. Most prominent ones are the alkaline salts; they liquefy mucus, act as laxatives, clearing out the bowel, stimulating peristalsis, and stimulating muscular contraction of the gall bladder and ducts, which is of undoubted benefit in cases due to catarrhal inflammation of the duodenum. Gall stones that cause pain indicate an operation. In obstructive disease where a stone has been pushed down into the ducts operation is positively indicated, and it is a matter of necessity if we want to prevent the worse after-effects, general inflammation of the biliary system, cholemia, pyemia, and septic conditions to which most of our patients succumb.

Various authors have laid down certain lines and indications for surgical treatment. In cases where there is a stone in the duct, in a patient where there seems to be little hope on account of the advanced stage of the disease, it has been proposed not to subject the patient to the severe operation of opening the duct, but simply to open the gallbladder and drain it, and at a later period, when the patient has sufficiently improved, to open the duct.

P. F. BARBOUR, M. D., Secretary.

THE AMERICAN PRACTITIONER AND NEWS

VOL. 33.

"NEC TENUI PENNÂ.”

MARCH 1, 1902.

H. A. COTTELL, M. D., M. F. COOMES, A. M., M. D., Editors.

No. 5.

A Journal of Medicine and Surgery, published on the first and fifteenth of each month. Price, $2 per year, postage paid.

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THE OSTEOPATHS GET IT IN THE SOLAR PLEXUS IN NEW YORK AND KENTUCKY.

The osteopaths made a desperate effort to secure the passage of a bill through the Kentucky Legislature to grant them all of the rights and privileges that the regular physicians are entitled to except to practice major surgery. They employed the best legal talent in the State to plead their cause before the committee to whom the bill had been referred. Suffice it to say that the committee very promptly put it to sleep, and it is to be hoped that it will sleep the sleep that knows no waking, and that all bills of a similar nature will meet the same fate if such should be presented to any legislative body for consideration.

The passage of such a bill as was presented to the Kentucky Legislature in any State would make it a haven for quacks, as it would enable the osteopaths to register anybody who would pay their examining board enough money. In short, it would be a get-rich machine the like of which has not been heard of in modern times.

The New York Legislature was asked to pass a bill with absurdities in it similar to those in the Kentucky bill, but the committee recognized the "ass's ears" in time to send him to grass for an indefinite period.