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. The accounts of their re¬ of the less advanced class of postgraduate workers. Vienna, sults have to be read by all who keep abreast with progress it is asserted, is not as prosperous a city now as Berlin, the in these fields. finances of Austria are not in as satisfactory a condition as THE SEROTHERAPEUTIC INSTITUTE. those of Germany, the money available for university pur¬ Professor Paltauf is also the director of the State Sero- is there a to poses less,2 has been, these critics hold, tendency therapeutie Institute of Vienna and one of the most inter¬ in the Austrian "in-breeding" faculty, the average and espe¬ esting forenoons I spent in the city was devoted to visiting it the Viennese is no lover of is to cially average travel, prone in his company. The institute is divided into two parts, one be satisfied with "good old Vienna," and to know but little for the strictly scientific work of the institute and the business and less of on the world eare what goes in outside it; finally, office, the other for the preparation of serum in large quanti¬ it is maintained that, with notable exceptions, of course, the ties. The former should be situated close to other scientific efforts of the have been too toward faculty devoted exclusively institutes and close to the postoffice, express office and tele¬ and too little of the teaching the known toward the discovery graph station; the latter should be placed where room for hitherto But even these are it should unknown. if critics right, extensive stables is available, and where the animals can be be it is difficult to statement remembered that make a which exercised in the open air. These different needs were met by i* just in general without appearing to be unjust in particular. establishing the scientific work of the institute and the busi¬ There are in Vienna a of most undoubtedly to-day number the ness office for the distribution of serum temporarily in the energetic and productive scientific investigators that exist in bactériologie institute of the "Rudolfstiftung," while the de¬ the of broad men world, widely-traveled men training, with partment for the preparation of serum on a large scale was the highest ideals and with great capacity for work who are instituted in the Court of the Kaiser Franz Joseph Hospital in demonstrating constantly their right to positions in the front the extreme outskirts of the city. Here stalls have been built rank of medical research. for 50 horses, a piece of ground has been set aside for a riding for work in The material clinical, anatomic and pathologic ring in which the horses are saddled and ridden for a certain Vienna is its concentration in and about the superabundant; length of time each day for exercise, and a very complete has made work there huge Allgemeine Krankenhaus medical serum-institute, occupying an area of 360 square meters, has convenient for the student. a more very Recently centrifugal been constructed. On the south side of the latter, an has operating tendency been noticeable; the work at the Rudolf Spital, room 51 meters square has been built. The description of the the Kaiser Franz-Josef Spital and the Kk. Wilhelminer Spital Institute given by the resident assistant, Dr. Jellinek3, should is rapidly increasing in importance. be helpful to any planning a similar structure. Anatomy and histology are well taught in Vienna in the In drawing the plans for the institute, the principle of two anatomic one the of Prof. Carl institutes, under direction separating as completely as possible from one another the Toldt, the founder of modern conceptions concerning the de¬ individual departments with their laboratories for the differ¬ of velopment the alimentary tract and the peritoneal cavity, ent kinds of work was adhered to. The various staircases to¬ and the author of the magnificent anatomic atlas which bears gether with the entrance corridor occupy the middle of the his the under the of Emil name, other leadership Prof. Zuoker- building; the machine-rooms are in the cellar; on the ground well known his book on kandl, through topographic anatomy floor on the left are the rooms for collecting and preparing and on the his original researches comparative anatomy of the serum, on the right the laboratories for chemical work and brain. Dalla Tandler and are members of Rosa, Grosser active the small rooms used for testing and standardizing the sera. the staff. The are histologie courses ably conducted by Pro¬ Upstairs, on the right, completely isolated from the other fessor von and his Ebner assistants, Schaffer and A. Rabl. parts of the building, are the laboratories for bactériologie The anatomic museum is rich in beautiful the preparations; and histologie work, with all necessary equipment; on the skeleton and erected amusing groups designed by Hyrtl, are same floor, on the left, are two apartments for resident assist¬ among the curiosities to be seen there. ants. Each part of the building has its separate entrance Toldt's atlas, like Spalteholz' Atlas of Human Anatomy, is a from the central halls. of two works have triumph modern bookmaking art; these The institute has been fitted up with the most modern ap¬ far and will gone go farther toward making anatomic ideas pliances in the way of thermostats, sterilizers, autoclaves, more exact ever and toward than before unifying and simpli¬ vacuum-pumps, etc. The arrangements for leading the horses anatomic nomenclature. The illustrations in both atlases room fying in and out of the operating and for drawing the serum are excellent and are invaluable not only as an aid to dissec¬ have been made most convenient and simple. The blood ob¬ but as a reference book in the work of the tion, practical phy¬ tained by sterile puncture of the vena jugularis is received sician and find it surgeon. Every practitioner would profitable in sterilized glass cylinders (provided with an ingenious to own and use at least one of these atlases. Both Spalte¬ cover, so arranged that the jars can be filled without entrance and holz Toldt have already been translated into English. of air), and placed in a cooling-room for two days to let the Professor Physiology (under Exner's direction) is just mov¬ serum separate well. The serum is then transferred under ing into a fine new laboratory in Vienna. The new building aseptic precautions into large flasks and again allowed to sedi¬ is the older latter is adjacent to structure; the now to be ment for six weeks in the cool room, nothing being added to to given over neurology (under Obersteiner) and to one or two the serum as yet. By this time the serum has become quite other sub-departments. clear ; through quiet standing nearly all of the blood corpuscles It seemed to me that the best most organized and actively and flocculi of fibrin have fallen to the bottom. The serum is 2. The income of the University of Berlin for the year 1903 3. Jellinek, O.: Die Abteilung f\l=u"\rSerumgewinnung des stadt\x=req-\ was 3,406,914\m=1/2\marks; that of the University of Vienna for serotherapeutischen Institutes in Wien. Wien. klin. Wchnschr., 1897 was only 1.159,594 florins. 1903. pp. 1403-1405.

Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on 06/14/2015 then transferred to other flasks, in which it is treated with of this arrangement is obvious when one remembers the neces¬ carbolic acid (0.5 per cent.), a precipitate of albumin, phos¬ sity of isolating newly purchased horses until they have been phates and cholesterin forms, and is filtered off, and the proven to be free from disease, the separate stabling of espe¬ filtrate is preserved in large, flat-bottomed flasks in the cool¬ cially inoculated animals, and the quarantine of infected ani¬ ing chamber. mals. The institute has its own blacksmith constantly in at¬ The chemical laboratory has been well-planned and though tendance. Regular weekly visits are made by a veterinary not large, has in it everything necessary for the work, in¬ surgeon, and he may be called on at any time in case of need. cluding hood for gases, work tables, sets of reagents, precision- Professor Paltauf told me that many of the best horses used balances, water and gas, vacuum-pump connection, com¬ in serum manufacture developed amyloid; they have hem¬ pressed-air connection, centrifugal machine and contact for orrhages into the liver, become icteric and die. Nearly a dozen electrical power for motors. fine animals have been lost from this cause. The bactériologie laboratories have broad, high windows, In view of the disappointing results with antistreptococcus lighted from the north; the work tables at the windows rest serum elsewhere, it was a surprise to me to find that the par¬ on iron brackets set into the waff, so that the floor-space re¬ ticular antistreptococcus sera prepared in Vienna under Pal- mains entirely free; the tables are covered with white enam¬ tauf's direction are highly valued. The opinion there seemed elled lava, a material which resists chemicals and dyes better to be unanimously in favor of the use of Moser's serum in than glass or oak, and which on account of its white color scarlet fever and of Paltauf's new serum against streptococcus makes for cleanliness. The largest thermostat measures nine infections of the puerperium. The difference between these square meters and is two and one-half meters high; it is sera and that of Marmorek is this: The Vienna sera are heated by gas, can be exactly regulated for any temperature prepared by direct inoculations of streptococci of human ori¬ between 33 and 40° C. ; that it works well is shown by the gin, the serum for scarlet fever by immunization against curve of the self-registering thermometer attached. A special streptococci from the throats of actual scarlatina patients, the wash-room has been provided for this laboratory with its own serum against puerperal infection by immunization against sterilizing apparatus, in order that tubes, glass vessels and streptococci taken directly from human puerperal infections. other objects used here need not be removed for cleaning to The Viennese believe that the passage of a race of strepto¬ other parts of the building; this is one of the many safeguards cocci through animals makes it incapable of yielding results against contamination of the laboratory in which the serum such as they get by their direct inoculations from human is prepared. The machinery in a sero-therapeutic institute is cases. An assistant of Chrobak's at a meeting of the Aerzt- rather complex and a good mechanic is essential to the estab¬ liche Verein which I attended, reported a series of puerperal lishment. A four-horse power electric motor runs a small infections treated with the new serum, in which the favorable ammonia refrigerating machine, and a half-horse power motor results obtained were truly striking. Every case in the series runs a salt-water pump which pumps the concentrated solu¬ in which the infection was due to streptococci alone, it is as¬ tion of magnesium chlorid cooled by the machine to —10 de¬ serted, was cured; bactériologie study of the few fatal cases grees C. from the refrigerator to the tubes which cool the demonstrated mixed infections with other bacteria. rooms in which the serum is kept in the parterre. To the THE AERZTLICHE VEREIN. attached when larger motor can be desired the air-pump, The Aerztliche Verein, by the way, is superbly housed in which air under on one and a supplies pressure the hand, Vienna, and it says much for the enterprise, generosity, and vacuum-conduction on for in the the other use laboratories; artistic sense of the medical profession of that city that it motor also a for hot-water the same drives pump circulation should have provided itself with such a home. The reception- in the A vacuum for building. apparatus concentrating serum, rooms, auditorium, and library are admirably arranged, and it or for it to is situated in evaporating dryness, a special room is not the practical needs alone of the busy medical men that near by. Inside it are a number of horizontally placed iron have been considered; the exquisite furnishings, the balus¬ in which hot water circulates. The serum in a thin plates, trades, the group of busts of famous Vienna medical men, in flat sterile dishes is on layer glass evaporating placed give the place an air of elegance and ease. I could not help these iron plates; the apparatus is closed air-tight, and the but wish that the profession of Chicago and of other great air inside exhausted the vacuum the by pump; temperature American cities might soon, with the help of the excellent or¬ is maintained at from 27 to 30 and the degrees C, evaporation ganization which has recently been going on in connection with on with and to goes great rapidity without any injury the the medical societies, see its way clear to supply the money labile constituents of the serum. After the evaporation has for and to build similarly practical and beautiful buildings. been carried far filtered air is allowed to enter enough, the The advantages of a permanent headquarters for the and the removed. When profession apparatus product necessary the in a large city-are almost incalculable. The benefits derived whole can be sterilized a stream of apparatus by passing extend in a whole series of directions—not the least important steam it. superheated through of which is the social. Such a professional home goes far to A Buchner's of a of large press, capable exerting pressure elevate the standards of a group of men; it is an influence 350 atmospheres, forms a part of the outfit. My attention was which tends to dignify, ennoble and refine the profession. At also drawn to a kind of which special protective paint has the time of my visit the Vienna gynecologist, Professor serviceable. As it proved very is well known, is extremely Chrobak, was president of the Verein, and Professor Paltauf difficult in workrooms to find a that bactériologie covering will was its secretary. stand steam sterilization. In the Vienna Institute a Dutch- (To he continued.) French substance called "ripolin" has been found very satis¬ factory. It has often been subjected to temperatures of 100 degrees C, and while the original white color has turned a li'tie yellow, blistering or scaling lias not occurred. The Therapeutics. ripolin is therefore far more durable than Japan black or enamel paint. [It is the aim of this department to aid the general practi¬ The stables for the horses are models of cleanliness and tioner by giving practical prescriptions and, in brief, methods order. It is discouraging to an American to think of how ex¬ of treatment for the diseases seen especially in every-day prac¬ pensive it would be to keep the horses and the stalls at home tice. Proper inquiries concerning general formulae and out¬ in the princely way they are cared for here. It is easily pos¬ lines of treatment are answered in these sible in Austria and Germany to obtain a skillful, conscien¬ columns.] tious Dienerschaft with a moderate money-outlay; in America the cost of the same skill and help is almost prohibitive. The Acute and Chronic Nephritis. newer stables are so constructed that they can be subdivided In considering the treatment of nephritis it must be ascer¬ into small, completely isolated compartments; the desirability tained whether or not the condition is an acute or a chronic

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