papers, one on rabies and the other on the differentiation of syphilis, are important contributions. The discovery of the Negri bodies in rabies as a positive diagnostic sign is a strong point in this horrible disease. Instead of waiting now eighteen days, possibly three weeks, to make a diagnosis, the diagnosis can almost be made at once, and it is easy for us to see what an immense saving of time there is, and what great comfort there is in making such a diagnosis. I can only speak of the spirocheta in a clinical way. Dr. Andrews has done some of this work for me, and I have two or three cases under observation. One of them I am treating in a routine manner for syphilis. That patient is now being given two grains of the protoiodide of mercury a day. The chancre is disappearing rapidly; the malaise and general ill-feeling that accompany this period of intoxication are fast disappearing.

To show Dr. Andrews' accuracy in this matter, I wish to mention a case that I recall in the last few days. He declined to make a positive diagnosis, and requested a further examination in this case. In this particular individual there were two ulcers which presented a beautiful clinical picture of chancres, although we know it is quite unusual to see more than one ulcer on the penis. A second examination was made. Those who treat syphillis recognize what an immense advantage there is in making a quick diagnosis. We all have patients to meet weekly on account of the fact that we are not positive as to the diagnosis. It is frequently the case in my own practice that patients leave me and consult other physicians, because I can not tell whether they have syphilis or not, nor do I think any man can tell positively in the very early stages. Hence we are compelled to wait five or eight weeks before a positive diagnosis can be made. This is a period of great trepidation. It means an uncomfortable period

of expectancy, and a period during which the physician finds no pleasure in treating the case.

I do not know of the results of any research that can be more valuable than these. Now we can attack syphilis in the initial stage. We can attack the virus. After the diagnosis is made, we need the intelligent cooperation of the patient, so that there may be great reduction in the tertiary symptoms. I think in the great majority of cases, say 95 per cent., there should not be tertiary syphilides if patients are treated early.

THE DIAGNOSIS AND TREATMENT OF GALL

STONES.

BY GEORGE R. WHITE, M.D., SAVANNAH.

The last few years have shown remarkable activity in research upon the diseases of the gall bladder, and a corresponding improvement in our methods of diagnosis and treatment. The recent works of the Mayos, Murphy, Ochsner, Furgason, Deaver, Lilianthal, Bevan and Richardson in this country, with Mayo, Robson, Moynihan, Kehr and Courvoisier, and others, abroad, have made it necessary to rewrite our literature on the gall bladder almost entirely. The classical symptoms of gallstones, namely, jaundice, tumor of the gall bladder and passage of gallstones, will no longer hold good. Jaundice is absent in over 80 per cent of all cases, and when present and unremittent, indicates some disease other than gallstones. The gall bladder is contracted more often than enlarged; and the actual passage of a gallstone is a much less common occurrence than is generally supposed; while the real symptoms of gallstones may be found enumerated among the classical symptoms of chronic gastritis and dyspepsia. Equally radical have been the changes in the views of pathology and treatment.

FREQUENCY.

Cholelithiasis is a very common disease. About one in ten subjects coming to autopsy show gallstones, and about one out of five of adult females. The histories show that in many of these the disease was not

suspected during life. In some the stones had given no trouble, while in others they had caused pain and inconvenience, as evidenced by extensive adhesions about the gall bladder.

CAUSE.

The cause of gallstones is a low-grade infection of the gall bladder or bile passages, with the production of an abundant supply of mucus, from which is precipitated the stones. They do not come from the bile alone, but from a chemical action between bile and mucus, and are never produced except as the result of infection. A foreign body in a healthy gall bladder will not produce a stone. Mignot has occasionally produced them, experimentally, in animals by introducing into the gall bladder attenuated culture of streptococci, and their formation was rendered practically certain in every case if a foreign body was introduced at the same time.

Gilbert has likewise produced them by attenuated culture of typhoid bacilli. It has also been shown that during an attack of typhoid fever the bile is often infected, and starts an inflammation of the gall bladder of greater or less severity. After a time the bile, like the blood, produces the Widal reaction and the bacilli clump; so that an attack of typhoid fever may produce both the low-grade inflammation necessary to the production of mucus and a foreign body in the form of a clump of bacilli as a nucleus for the stones.

A large number of gallstone cases show previous infection somewhere in the abdominal cavity. In Ochsner's statistics 35 per cent of his cases had had typhoid fever, and about an equal number had suffered from chronic appendicitis. Infection from the female generative organs is also a cause, and may account for the higher percentage of trouble among women than among men.

PATHOLOGY.

After the gallstones have formed, it is possible for the inflammation to subside and the stones remain latent throughout the patient's life, though this happy termination is not the rule. They produce trouble by blocking the bile passages and by keeping up the inflammation. If they lodge in the cystic duct without starting up inflammation, the bile becomes absorbed and the gall bladder becomes filled with a clear, viscid mucus, and may dilate to a large size. These cases are rare; usually inflammatory changes predominate. The walls of the gall bladder become sclerotic; fourth to half-inch thick; adherent to surrounding structures, and gradually contracts to a fibrous mass not larger than a lemon.

The complications are numerous. The most common is an acute exacerbation of the inflammation, following blocking of the cystic duct with a stone, and leading to rupture or gangrene of the gall bladder, with its accompanying peritonitis. The rapidity of a process of this kind is surprising, resembling fulminating appendicitis. Other complications are empyema, ulceration and perforation into the peritoneum, or some of the neighboring organs; also, abscesses about the gall bladder or in the liver.

If a stone passes into the common duct and lodges there the pathology is equally varied. It usually produces a ball-valve action, which allows the bile to pass intermittently. The duct dilates behind the stone; the gall bladder contracts, following Courvoisier's law, and more or less cholangitis is present, characterized by enlargement of the liver, jaundice and fever, with sudden exacerbations and remissions.

If the stone lodges at the ampulla it may ulcerate through and escape, or it may remain and produce a