have detected the disease, except in the rare cases where the thinness of the abdominal walls permits palpation of a gall bladder distended with stones. The clinical history of cholelithiasis is therefore identical with that of hepatic colic. Treatment, then, has a two-fold object; First, to get rid of stones already formed, and second, to prevent the formation of more. Many experiments have been tried with a view to discovering some drug capable of dissolving gall stones; and with success so far as the laboratory is concerned, but not so as to the body. Ether, chloroform, turpentine, olive oil and many others have been tried and found wanting. It requires a deal of credulity to imagine that any remedy taken per os will pass through the stomach, enter the duodenum and then travel the whole length of the common and cystic ducts in a direction contrary to the current of bile until at length it reaches the gall bladder in a sufficient degree of concentration to dissolve the stones there present. It may be safely said that there is no medicinal treatment for gall stones already formed other than those measures directed to the relief of pain and spasm. To prevent the formation of stones in a patient who has suffered from bilious colic may be quite possible, though appearances are often quite deceptive and conclusions too often prove mistaken. Long intervals may exist between attacks in cases untreated, and spontaneous cures may result, all the stones having been expelled. Again, in cases under really efficient treatment calculi already formed may continue to give rise to attacks of colic and seem to argue the futility of the measures in use. Finally gall bladders distended with concretions are often found post mortem in subjects who have never suffered from their presence. In short, the whole subject is beset with difficulties

and uncertainties. However, it seems rational to suppose that the salts of sodium, which, as shown in the laboratory, possess the power of preventing the preciptation of cholesterine, may be given in sufficient doses, long continued, to prevent the formation of gall stones and finally cure the disease, and the consensus of opinion favors their use. The phosphate, bicarbonate or sulphate may be given, singly or in combination, in accordance with individual fancy, and many saline spring waters are used with apparently great success. During an attack of colic-while the stone is on its passage through the ducts-the leading indication is by opiates to relieve the pain, favor relaxation and promote expulsion of the calculus. But for those cases in which there is frequent repetition of attacks, or in which there is impaction, surgery offers the best and surest chance of success. The operation suitable will be different according to the circumstances. Removal of the gall bladder, incision of the gall bladder with extraction of the stones and immediate suture, and cholecystenterostomy by means of Murphy's button have all been practiced in many cases with success. Where the concretion is impacted in a duct, the latter may be incised, the stone removed and the opening closed by suture. Or a combination of operations may be necessary. In the case which forms the basis of this article none of these operations could have been practiced on account of the adhesions and other inflammatory changes which had taken place. But even here there might have been a brilliant chance for surgery. It would not have been a very difficult or dangerous matter to incise the duodenum, to dilate the orifice of the common duct, liberate the imprisoned concretions and then close the duodenal incision in the usual manner. Could this have been done

sufficiently early-before the extensive degenerative changes took place in other structures-the unhappy subject of this sketch might be living and well to-day.

DISCUSSION.

Dr. L. W. Hubbard: Mr. President and Gentlemen :— I do not know that I can add anything to the very fine discussion of this disease by Dr. Martin. His discussion of the case that he had, covers a case that I had myself and was so unfortunate as to lose after four days' sicknessthat being the third attack.

I will mention only a few points that occur to me--one is that age has a great deal to do with this disease,-while some more advanced in life would not recover, a younger person would. It is found in people of sedentary habits, fleshy and perhaps addicted to the pleasures of the table. It is sometimes caused by inflammation of the mucous membrane lining the gall ducts, flakes of mucus then have formed and are thrown off and inclosed by deposits from the bile, forming these gall stones. This is a form of gall stones formed from the bile. The chemical part of the bile should be neutral or alkaline, for if the bile becomes inspissated and thick, which conditions are favora ble to the crystallizing of the bile salts, then we have a condition more favorable to the formation of these bodies.

Now, if that is the case the proper treatment is to keep the bile alkaline, then if that can be accomplished, the next point is to pay attention to the condition of the patient. The patient should be restricted in diet and advised to take those articles of diet which will be less

likely to bring on indigestion, confining our patient to those foods that are devoid of fats, sugars, starches and carbohydrates. Give lean meats, recommend plenty of free out-door exercise, in order that this exercise may bring on better change of tissue and carry away the particles of fat. If this is taken pretty freely and there is some obstruction to the flow of bile, we find that it is more easily overcome, so that in this case we bring about the condition more favorable to this change of the regulation of the bile and less favorable to the deposit of the gall stones. I think in advising our patients to take out door exercise, we get them into oxygen and the patient is more cheerful and so improves rapidly, but once given an attack, I know no remedy so useful as opiates and possibly large enemas that will stimulate the action of the bowels.

Intestinal Indigestion; Its Dietetic and Rational Treatment.

By William Henry Porter, M. D., Professor of General Medicine and Pathology in the New York Post-graduate Medical School and Hospital, etc.

This subject has been chosen because there is very little attention paid to the discussion and treatment of intestinal indigestion in our modern works upon medicine, and also for the reason that the malnutrition consequent upon intestinal indigestion is largely responsible for almost every disease that occurs in the human organism. In many textbooks this subject is entirely ignored, and at best it is only given a passing notice. In one of the recent and standard works upon the theory and practice of medicine, eleven lines only are devoted to this important problem.

To perfectly understand intestinal indigestion necessitates a clear conception of the chemical composition of food-stuffs and the transmutation processes that they must undergo before they can be absorbed and assimilated. This accomplished, the abnormal is quickly and accurately detected.