At 5 p. m. of the same day hiccough set in, and we felt that this was the beginning of the end. The hiccough was controlled by a dose of morphine given by his physicians in my absence, but not before the cannula had become disarranged so that it would not drain the bladder. On the 8th there was very little change in his condition from that of the previous day, and it was determined to open the bladder at once. After the usual preparation the bladder was opened under chloroform, the operation requiring a very short time; bladder contained bloody urine, large blood-clots, and pus, which was washed out with a warm boracic acid solution. A large drainage-tube was inserted into the bladder and a dressing applied. Patient came from under the chloroform quickly but the secretion from the kidneys gradually grew less, and the patient died thirty hours after the bladder had been opened.

I feel that if the bladder had been opened the morning I first saw him, under a local anesthetic, the results might have been different; the patient might have gotten well. However, his condition was SO unfavorable that I feared any surgical procedure further than simple drainage of the bladder.

In reviewing the case, I believe now that the advice given him by me in 1898, not to have a cutting operation, was wrong; and while this would have been good advice in the majority of cases, there are cases like this one, where the patients will not have their strictures dilated sufficiently often, and who live some distance from a competent physician, who should have their strictures cut, thereby removing the cause from which this man lost his life.

GUTHRIE, KY.

GALL STONES: REPORT OF A CASE.*

BY W. R. BURR, M. D.

A snap diagnosis of gall-stone colic is often made by the careless physician when called to see a case complaining of pain in the right hypochondriac region, and yet it seems to me that such a conclusion, without well-marked signs and symptoms and the finding of gall stones in the evacuations, is uncertain.

On the other hand, it is empirical to attribute all colicky pains to disturbances of the digestive apparatus and have only one diagnosis for such manifestations. We should not fall into the habit of our osteopathic friends, and have but one cause for all physical pains and aches. No matter what the patient's affection is, they have a stereotyped expression to explain the cause of the trouble, namely, "a constriction of the pyloric end of the stomach."

The great Napoleon thought the stomach "the seat of human welfare," and physicians who are not of an investigating turn of mind are apt to hold the stomach responsible for the major portion of the maladies that derange the human machinery.

Genuine gall-stone colic has every indication of a fatal ailment, and not infrequently one thus affected does succumb to the shock produced by an attack. One meets, now and then, a case in which severe paroxysmal pains lead him to suspect gall-stone colic, but in which the other signs and symptoms are wanting, and the problem that presents itself is a perplexing one.

But to the case which I am to report, which has been a very interesting one to me, as it was misleading, and I only arrived at a diagnosis after careful investigation.

I was called late in the afternoon of September 29, 1901, to see a gentleman sixty years of age, who was reported to be suffering from a violent spell of intestinal colic. The messenger said he had suffered an attack the previous night, and that a physician in a neighboring town had sent him some morphine tablets to quiet him, not being able to make him a visit. This failed to relieve him until he had taken several doses at hourly intervals.

When I arrived at his house I found him suffering excruciating pain and begging for relief, saying that if he did not get relief in a short while

*Read before the Southern Kentucky Medical Association at Adairville, Ky., April, 1902.

he believed he would die. He was sitting, bent nearly double, in bed, it being impossible for him to assume the recumbent posture. His face was pallid and anxious in expression; he was in a cold, clammy sweat, and his pulse was going at a rapid rate. The pain, he said, had commenced suddenly in the back, at the lower border of the ribs on the right side, and radiated to the pit of the stomach, at which region there was tenderness but no apparent distention. There was slight tenderness over the gall-bladder, but no enlargement about the liver that I could discover.

His suffering was so acute that I decided to give him relief for the time, if possible, and then give his case further investigation. I gave him a fourth of a grain of morphine and one hundred and fiftieth of a grain of atropia, and had the attendants apply cloths, wrung out in hot water, over the seat of pain. In about fifteen minutes he expressed himself as entirely easy, and wondered why the repeated doses of morphine he had taken for the paroxysm the night before had been so slow in giving him relief.

On further examination of his case I found that although his pulserate had been high, and the attack had been preceded by chilliness, his temperature was only half a degree above normal. There had been no pain of any consequence in the right hypochondriac region, but there had been some rigidity of the muscles. There was no evidence of distention from accumulation of gas in the stomach and bowels; his urine was scanty and highly colored, and there was constipation. He said that his evacuations for a week or more had been small, pasty, and light-colored. He was not jaundiced at that time, but was slightly so in about forty-eight hours. A bedside urinalysis was negative in its results, except that I felt sure of the presence of bile in the urine.

The severe and sudden paroxysmal nature of his trouble, unaccompanied by any marked elevation of temperature, and the absence of gaseous distention, caused me to suspect gall-stone colic. But as the signs and symptoms were somewhat misleading, and repeated attacks in his case occurring at short intervals for a number of years had been called colic, resulting from indigestion, by other and more experienced practitioners than myself, I deferred giving a decided opinion.

The patient informed me that about twenty years ago he was troubled with severe and recurring attacks of colic, which the physician who attended him called "bilious colic," and that he gave him olive oil freely, which, after a short time, afforded him relief. He then had no

further trouble for four or five years. During the past fourteen or fifteen years, though, he has been frequently an intense sufferer from these attacks, and says that the physicians who have treated him have pronounced his trouble "indigestion of the worst form." He says that they always gave him morphine to ease him during the attacks of colic, and would then give him tonics and digestive agents.

During the illness in which I attended him he had five paroxysms of colic, at intervals varying from twenty-four to forty-eight hours. The treatment was morphine and atropia for the paroxysms to give relaxation, which never failed to quiet him quickly and give relief until the next passage of stones. A brisk purge of calomel, ipecac, and soda, followed by a full dose of phosphate of soda, was given, and olive oil was given him in large doses every four hours for a number of days. He also got each morning a dose of the phosphate of soda.

Directions were given to save all his evacuations and search them for gall stones by mixing them with warm water and straining through several thicknesses of cheesecloth.

He was confined to bed for about two weeks, and during that time passed twenty-one irregular-shaped gall stones, varying in size from that of an ordinary navy bean to twice that size. Besides these stones, innumerable ones the size of a pin-head were found in the residue after straining the evacuations.

Realizing that when gall stones are present attacks will recur, endangering life until they are all passed or are removed by the surgeon, I felt very much like the case was an operative one when the first stones were found. But in a country practice we can not always treat cases as we should like to treat them, and as an operation was not expedient I decided to do the best I could with medicinal agents, and tide the patient through the stormy passage of the stones already formed and seeking exit, and to prevent others from forming as best I could.

I saw the case the 12th of October of last year, and since that time he has had no symptoms of a return of his trouble, and he is in better health than he has been for years. But he is still under treatment, with a view of keeping his digestion in order and of obtaining a free flow of bile, hoping thereby to prevent the formation of stones.

AUBURN, KY.

PARALYTIC DEMENTIA.*

BY ERNEST RAU, M. D.

There is no form of disease complicated with insanity which is more ominous and presents less hope of recovery than that known as paralytic dementia or general paralysis of the insane. We are now fairly acquainted with its history, symptoms, and invariable termination, but are still ignorant of its remedial therapeutics, and for a long while little was known of its pathology, which still gives rise to much discussion. The names which have been applied to it among American writers are: General paralysis of the insane, progressive general paralysis, general paresis or paralysis, paralysis of the insane, paralytic dementia, paretic dementia. A much used and expressive term is "softening of the brain." Gray defines it as a cerebral disease of chronic remittent type characterized by dementia of very gradual onset usually merging into a mania or melancholia, generally with stupid and expansive delusions and accompanied by tremor, ataxia, pupillary alteration, and eventual paresis. In 1822 Bayle described it, considering it a chronic meningitis. From that time until the early 50's the most attention was given it by French physicians. In 1854 Erlenmeyera German wrote upon it, and since that time it has been considered by writers of every civilized nation, the names of whom are too numerous to think of looking into, much less to mention. Most of the cases received into the hospitals for the treatment of such diseases are in the more advanced stages and prove rapidly fatal.

It would be useful for every general practitioner to acquaint himself with the signs by which the disease may be recognized in its early stages. That this knowledge is needed, is shown by Dr. A. E. McDonald, former superintendent of the New York City Asylum for the Insane, who said that an examination of the certificates sent to the asylum by physicians in private practice shows that they recognized the true character of the disease in but three cases out of thirty-five in which they had made affidavits. Physicians connected with public institutions made a somewhat better showing, detecting the form of insanity in thirteen out of thirty-five.

Most of the American alienists have conveniently divided general paresis into three stages: First, prodromal; second, maniacal or melan

* Read before the Kentucky State Medical Society, May, 1902.