The Etiology and Diagnosis of Cholelithiasis. that the pain in the majority of instances is due to infection. Dr. William Ruoff stated that no common etiologic factor Jaundice as a diagnostic factor is very misleading. He never could be assigned to all cases. Age is an important factor, operated on acute cases, but if the symptoms persist, then the value the majority of cases occurring between the ages of 40 and 60, of operation must be considered. The œ-ray is not of and the more frequent occurrences in females he laid to the much value in diagnosis. He did not recommend operation in mode of dress and pregnancy. The influence of age might be cases of acute common duct obstruction. The operation, if manifested through the loss of contractile power of the bladder, performed, should be done early. He does not approve of thus favoring retention and the lack of resisting power of the operating in private houses. He emphasized the value of body fluids. He felt that too much importance is attached to careful preparation of the patient prior to operation, including temperament, gluttony, excessive indulgence in meats and fats, careful urinalysis. Stomach analysis is not of much value, ex¬ heredity and climate. He discussed in detail the different cept in cases of acute leueocytosis. He favored drainage of the varieties: (1) Pure cholesterin stone; (2) laminated cholesterin gall bladder rather than its removal, unless there was some in¬ stone; (3) ordinary gallstones; (4) mixed bilirubin-calcium dication for the latter procedure. stones; (5) the rarer forms, such as (a) amorphous stones, Dr. Wilmer Krusen referred to the case of a woman, 32 of resembling pearls; (b) chalk stones; (e) concretions sur¬ years age, who had suffered with gall-bladder disease for a rounding foreign bodies; (d) casts of bile ducts. He then period of eight years without the true condition being sus¬ considered in detail the infective causes through the medium pected. The ¡r-ray failed to reveal the seat of the trouble. At of the portal circulation and through an ascending infection the operation for removal of a cystic ovary, forty-three stones from the common duct, and the influence of appendicitis, sal- were removed from the gall bladder and the woman made a pingitis, peritonitis, etc. The diagnosis was considered under good recovery. Another case was reported, in which an opera¬ three heads : ( 1 ) cases in which no symptoms have been pro¬ tion was done for appendicitis and the appendix was found not duced and which are usually discovered at autopsy; (2) tran¬ to be diseased. Two days later the patient had a pulse of 140. sitory symptoms of dyspepsia and abdominal and liver symp¬ temperature of 103 to 104, and a marked enlargement over toms; (3) those cases causing severe and, at times, almost the gall bladder. Operation showed an empyema of the gall fatal illness, which are most frequently met with. The symp¬ bladder, and 420 stones were removed therefrom, but the toms of jaundice, vomiting, hepatic and cystic infection were patient died within twenty-four hours from general peritonitis. considered, as was also the symptom of impaction. He believes that gall-bladder disease is as much a surgical procedure as appendicitis, and that the sooner the operation is Gallstone Disease, Remote Effects and Treatment. done the better for the patient. Dr. Samuel P. Gerhard stated that our efforts must be mainly surgical; that the gallstones, as long as they remained in the bladder, are perfectly harmless, but that the danger is Travel Notes. due to the liability of accidents in their passage through the common duct, considering under this head cholecystitis, em· AN INTEBSEMESTEAL EXCUESIOK pyema and gangrene, pancreatitis, fistula into a neighboring F. organ, peritonitis, etc. The medical treatment should be LEWELLYS BARKER, M.D. prophylactic, directed to preventing rather than curing the CHICAGO. disease. ( Continued from page 491. ) discussion. Vienna. Dr. David Riesman stated that the he had youngest patient One of the first questions a medical traveler is likely to be ever seen was 11 and the oldest 70 He that years, years. said asked by his colleagues on his return to America is: "How the essential features in the are in the of diagnosis pain region did you like Vienna?" And a layman hearing that a the gall bladder below the costal in the physician cartilage right para- has spent some months in Europe almost invariably remarks, sternal line, although the location of the is not abso¬ pain "I presume that you spent most of your time in Vienna," such lutely necessary, ¡>.nd anil He referred to vomiting jaundice. a fame has that city had as a medical center. Although in the case of a man, 37 of who from years age, had suffered Europe twice before, on neither trip had I been able to visit cramplike pains for a number of in the months, chiefly epi¬ the Austrian capital; I was all the more anxious, therefore, gastric and left unassociated vom¬ hypochondriac regions, with this time to arrange to visit the and its and to He had lost 20 in At city hospitals iting. pounds weight. operation, gall¬ meet some of its famous medical men. stones were found in the cystic duct; there was no and jaundice UNIVERSITY no tenderness in the gall bladder region. He also referred to OF VIENNA. several other The of founded as cases in which the characteristic symptoms were University Vienna, long ago as 1365, not present. In his experience the ¡r-ray has not been of value compels on account of its remarkable history the veneration in the diagnosis of these cases. He referred to the method of Dr. and respect of every visitor. And in that history the medical has a DaCosta of placing a cylindrical pad under the patient, so that faculty played very important part, not only in the the patient forms an inclined plane with the table, and then by development of medical teaching and practice, but also in the of gently rubbing with the hand, an enlarged gall bladder may forwarding the interests of science and arts in general. be felt. Referring to the pathogenesis, he stated that, without One has only to read that best of books on medical education, infection, the passage of the stone would cause inflammation Billroth's "Ueber Lehren und Lernen," to become impressed of with the of the gall bladder and ducts. He believes that many of the influence the medical faculty on the progress and cases of which were called biliousness were really due to gallstone development the University of Vienna as a whole. Great attacks. He referred to the occurrence of the condition after organizing minds like that of the distinguished Van Svvieten are even in the infectious diseases, and referred to a case diagnosed as duodenal rare, greatest of universities; fortunate are ulcer, which on operation proved to be an infected gall bladder. those institutions within which they occasionally develop. One such man The persistence of jaundice should suggest a stone or malignant may shape the destiny of a university for gen¬ disease. He expressed the belief that the surgical treatment erations; this has been true in Vienna, and it is pleasing to would assume the same place it had in appendicitis. find that the Viennese, conscious of their debt to a great mas¬ more than Dr. John B. Deaver stated that he had never seen nor ter, have in one artistic movement done their best operated on a case of gallstones in a colored subject. He to perpetuate the memory of Van Swieten in the city he loved divided the condition into two classes: cholelithiasis of the gall and for which he worked. bladder and of the affections common duct. The pain and VIENNA AS A MEDICAL CENTER. tenderness in the are epigastrium less frequent in disease of the While Vienna has long enjoyed the reputation of the common duct than in being gall-bladder inflammation. He believes most important medical center in Europe, and is still doubt- Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on 06/14/2015 less very great, there are some who think that it can no productive department in the medical faculty of the Univer¬ longer justly lay claim to the first place. That honor, they sity of Vienna was that of pathology, with Richard Paltauf think, now belongs to Berlin. The latter city has in the last as professor of general and experimental pathology and ten years made enormous strides forward; one would scarcely Anton Weichselbaum as professor of pathological anatomy. believe the change without actually observing it for himself; Along with these two well-known investigators are associated Vienna seems—some have even dared to say—a little provin¬ Gustav Gaertner, Arthur Biedl, H. Albrecht, Anton Gohn, cial by comparison. The explanation in all probability lies in Richard Kretz, F. Schlangenhaufer, Rud. Kraus, H. Winter¬ the growing prosperity of Germany, the increase in material berg, O. Stoerk, and . Sternberg, a list of names from which means in the capital of the German empire, the determination the fame of the university has really much to hope. Biedl's to seek the best men for university chairs irrespective of their experimental studies on the nervous system, Kretz's investi¬ nationality, and the encouragement of original research in the gations on the liver, and Kraus' original researches on bac¬ various departments rather than directing too much effort teriological problems and curative serums are among the most toward increasing the number of under graduate students and interesting of current conduction.