and free of calcium salts. For this reason no red meats, tea, coffee, chocolate, tomatoes, strawberries, bananas, nor limestone nor carbonated water should be taken. But the lentils should especially be used, because they not only require less oxygen for their assimilation but even carry oxygen with them. The oxygenated waters, instead of those charged with carbonic acid gas, should be used.

The salicylates promote the fluidity of the bile and together with the terebinthina group perhaps constitute the safest antiseptic. Probably the best antiseptic measures in the gall-bladder are those that prevent biliary stasis and promote normal gall-bladder activity. Local massage is to be especally recommended.

In typhoid fever, appendicitis, and other disorders attended with intestinal sepsis, the terebinthina group perhaps furnish the best prophylactic. They lessen both biliary and intestinal sepsis, besides exercising a somewhat solvent action upon biliary concretions. The treatment of the attack embraces measures for the relief of pain as well as those that facilitate the expulsion of gall stones.

It is estimated that less than fifty per cent of individuals affected with gall stones ever have clinical manifestations. Gall-stone colic is generally conceded to be due to the contraction of the muscular structure upon a calculus as it is forced into the cystic duct, so that in all instances of cholelithiasis attended with pain we are reasonably sure the offending calculus is small enough to have become engaged in the duct itself. Therefore we have positive indications for medicinal treatment.

The first steps in the treatment of the attack must of course be for the control of pain. Anodynes and anesthetics have been used. Coaltar derivatives, opium, alkaloids, ether, and chloroform have served. Perhaps the speediest relief, with the least undesirable after-effect, is obtained by the hypodermatic use of heroin hydrochloride in combination with atropine. Heroin is more analgesic and less constipating than morphine. Just as when morphine is used, small doses should be frequently repeated, lest the stone pass suddenly and a narcotic rather than an analgesic effect result. The agents assisting expulsion of the calculi may be divided into different classes. The action of one class is due to influence upon the tissues of the biliary tract. The action of the other class is due to influence upon the biliary concretion itself. Those that act upon the tissues perhaps exert a local sedative action, lessening muscular rigidity yet toning up muscular force.

A result is obtained analogous to that of cocaine upon the urethra. A spasmodically contracted urethra may resist the passage of the smallest metallic sound when cold, yet if cocaine, heat, or other local sedative be applied a sound of average size may easily pass. The drugs belonging to the first class are dioscorea villosa, carduus marianus, chionanthus virginica, and probably most cholagogues. The drugs belonging to the second class exercise a solvent effect upon the dif ferent component parts of the calculi, and though a solution may not be effected assist in the reduction and molding of the calculi. The drugs representing this second class are lecithin, olive oil, glycerine, the salicylates, ether, chloroform, turpentine, animal soap, nitromuriatic acid, the succinate of the peroxide of iron, valerianate of amyl, toluylendiamin, pichi, Carlsbad salts, and the alkalies in general.

Lecithin is perhaps the most active solvent of cholesterine known. The action of the various oils are dependent upon the lecithin they contain. At present olive oil affords the chief source for its administration. However, a large manufacturing establishment, in reply to a letter, has informed me that they hope soon to place pure lecithin upon the market. Gall stones composed of cholesterine, when raised to the temperature of the body, may often be molded as putty into any form, according to pressure. If lecithin does not put the cholesterine of the gall stone into solution it may so soften it as to permit this molding. The succinate of the peroxide of iron, hydrated, contains a large proportion of nascent oxygen, so that it is useful both as a prophylactic and an assistant in expelling calculi.

Pichi dissolves the mucus and products of inflammation that bind together the cholesterine and calcareous matter. Thus we see medicinal treatment instituted for the removal of the calculi should embrace the dietetic and hygienic measures suggested under prophylactic treatment, together with the combined use of both classes of drugs suggested as facilitating the explusion of biliary concretions. In addition to the lentils and oxygenated waters mentioned, eggs, milk (especially buttermilk), whole wheat and corn breads complete the requirements of a diet list. They furnish oxygen, phosphates, and lecithin.

Such local measures as massage, counter-irritants, especially the application of the salicylate of methyl and the use of either hot or cold enemata, are of some service. The internal medication should embrace drugs that favorably modify biliary secretion, that relax the spasmodically contracted ducts, lend tone to normal muscular contractions and

assist in molding calculi when possible, added to drugs possessing a solvent action upon the calculi. Therefore, the ideal prescription would contain lecithin as solvent for the cholesterine, pichi to dissolve the matrix of mucus, and dioscorea to assist expulsion. Perhaps the greatest number of cases reported where gall stones have been obtained has been due to olive oil; the succinate of the peroxide of iron is an old favorite; lately valerianate of amyl and toluylendiamin have been favorably reported. Personally, the use of the salicylates, dioscorea, and olive oil have served best.

A unique case occurring in the practice of Dr. E. S. Swain, of Smithfield, may be found of interest. This case has been reported and the specimens exhibited to the Louisville Pathological Society. Later the specimens were sent to Dr. William Rodman, of Philadelphia. The use of dioscorea and olive oil had been suggested in this case, which proved to be both biliary calculi and abscess. After several days' exhibition of the two drugs about thirty hollow gall stones were passed. The supposition is that the lecithin of the olive oil had dissolved out the cholesterine of the calculi, leaving the shell, composed of biliary and lime salts.

In the surgical section of the American Medical Association, in 1900, some few surgeons took the position that a diagnosis of gall stones was sufficient indication for immediate surgical intervention. However, many surgeons echo the sentiments of A. Chauffard (Year Book of Medicine, 1902), who says "Surgical treatment of hepatic colic is too frequently undertaken before medicinal treatment has been properly tested." Chauffard believes the relief obtained by surgical means is likely to be only temporary, and that the factors which previously caused the formation of calculi still remain present.

The intention of this paper is to urge the use of prophylactic measures in those predisposed by diathesis, sex, age, occupation, by intestinal or hepatic disorders favoring biliary stasis and sepsis and in those pre viously affected with biliary calculi.

It is not claimed that all cases of cholelithiasis can be cured by medicinal means. It is desired to emphasize the fact that internal medication, either alone or combined with surgical measures, must be instituted before a radical cure can result. In support of this it may be mentioned that only a very small proportion of cases of cholelithiasis ever require surgical intervention, and as mentioned by Chauffard. the etiologic factors remain and gall stones may recur after surgical treatment.

Furthermore, any inflammatory process or any foreign matter in the gall-bladder favors the formation of calculi. A case is reported where a secondary operation showed a portion of a stitch introduced at the first operation formed the nucleus of the subsequent calculus. Fiedler states that symptoms of gall stones occur after operative procedures in fifteen per cent of cases. Kelly shows that upon one in every seven cases operated upon by Kehr a second operation was performed. Again, the very occurrence of pain suggests the calculus is small enough to become engaged in the duct, and therefore is likely to be modified by medicinal agents. However, it may be said surgery and medicine are complemental. Neither is independent of the other. Combined, they accord a scientific and perfect treatment to cholelithiasis.

LOUISVILLE.

SURGICAL TREATMENT OF CHOLELITHIASIS.*

BY DAVID BARROW, M. D.

In considering the surgical treatment of gall stones it is necessary to bear in mind the anatomical structures involved in the operation. The healthy gall-bladder can rarely be mapped out through the abdominal parieties, and the fact of being able to do so is strong evidence of some pathological condition. The ducts in their relation to each other, and the common duct in its relation to the vessels in the gastro-hepatic omentum, must always be clearly pictured in the operator's mind, and the overlapping of the ducts by the portal vein must be remembered when it becomes necessary to incise the duct to remove a stone, an incision in the upper two thirds of the cystic and the middle third of the common duct being the safest. The acute angle made in the cystic duct makes it almost impossible to pass a probe from the gall-bladder into the common duct, and failure to do so after opening the gallbladder does not necessarily mean some obstruction. The three or four lymphatic glands found in the lesser omentum in the presence of inflammation are often enlarged and indurated, and may easily deceive the surgeon into believing that he has impacted stones in the duct to deal with. The peritoneal reflections of the gall-bladder, the gastro

Read before the Kentucky State Medical Society, Paducah, Ky., May 7-9, 1902.

hepatic omentum, and duodenal reflection must be understood, for during the operation it may be necessary to divide one or more of these folds. When the stone is impacted in the common duct, to bring it nearer the surface may require division of the peritoneum, binding down the duodenum, after which, with the finger in the foramen of Winslow, the gastro-hepatic omentum being brought forward, the operation can more readily be done.

The blood-vessels supplying the gall-bladder and ducts are enlarged in the presence of inflammation, and incision of either is often attended with troublesome hemorrhage. Richardson mentions a case where death occurred nine days after the operation from secondary hemorrhage from the cystic artery.

The large peritoneal pouch found in this region is a wise provision of nature, and renders operations upon the gall-bladder and ducts less hazardous. Into this pouch fluid will gravitate, and the end of a glass tube placed at the most dependent point will give satisfactory drainage; also will any escaping infectious material be confined and the inflammation resulting be limited, or if preferred a lumbar incision can be made for the purpose of drainage. This pouch will hold a pint of fluid before overflowing into the general cavity over the pelvic brim or through the foramen of Winslow. However, in most of the operations in this region the normal anatomical relations are destroyed, and we will not have the normal landmarks to guide us. From an infectious inflammation involving the gall-bladder and ducts the surrounding structures become involved, and on incising the parieties we find everything matted and unrecognizable, requiring extensive manipulation and dissection to remove the stones. The gall-bladder may be contracted-not larger than a filbert-with thick walls, or the ducts may be dilated, making the operation difficult and dangerous. When the inflammation is extensive it is not unusual to find adhesions involving the gastro-hepatic omentum, duodenum, the pylorus, colon, kidney, in fact, nearly all the structures above the pelvic brim on the right side. With these conditions, it may be extremely difficult to even find the gall-bladder or trace the ducts that the stones may be removed. Gall stones offend in a mechanical way and by producing infection of the bile passages, and in these operations special care must be taken to protect the surrounding healthy structure and in preventing the spread of the infection. Occasionally, in old cases, we find abscesses in the surrounding structures due to the extension of the infection from within