and found that in periods of from three to six months they were completely dissolved, thus proving that the healthy bile has the power of dissolving gallstones. The action of chologen is to bring about a secretion of healthy bile that has the power to act upon the calculus in such a way as to disintegrate and dissolve it.

Glaser's investigations have revealed quite a series of nervous symptoms, and he believes that cholelithiasis from beginning to end is a nervous affection and not an infectious disease. The first symptom is a functional derangement of the secretory nerves of the liver, especially the sympathetic; the second is the precipitation of cholesterin-infection of the bile; the third is catarrh and deposit of billirubin calcium; the fourth formation of a calculus in the neck of the gallbladder and development of local hyperesthesia followed by_gallstone colic.

In contradistinction to the idea that cholelithiasis is a nervous affection, is the supposition that it originates through infection from the intestine; that it is an infectious disease; the first stage being a bilious infection, the second a catarrh of the bile ducts, the third the formation of stones, and the fourth consisting of gallstone colics. Internal treatment of cholelithiasis has not been attended with marked success in fighting this supposed infection. On careful examination we find that the theory of infection is by no means to be considered as proved. As to the experimental production of gallstones by artificial infection of the gallbladder, Riedel remarks that the conditions necessary for making these experiments successfully do not exist in the human body. A mere injection of germs into the gallbladder does not produce gallstones. To effect this the cystic contractions have to be artificially inhibited and the bacteria, according to Mignot, should only be of attenuated virulence. In the case of biliary infection the only microbe to be really considered is the bacillus coli communis, and this seems to be merely a harmless germ when found on normal tissue, and pathogenic only when found on tissues that have undergone change.

Every physician is aware that gallstone colics frequently occur suddenly while patients enjoy perfect health, and disappear as mysteriously. Sudden anger or fright, a psychic shock, etc., suffice to produce this condition. It is difficult to understand how a psychic shock lasting five minutes can change a latent infection into an acute exacerbation. There must be a certain something else (Riedel), because the infection alone is not sufficient to account for the manifestations, and this something is the

point where the internal physician can and should start in order to work out a serviceable theory for the treatment of his patient.

Let

The germs of infection no doubt play an important role in the clinical picture of cholelithiasis, but probably they are not the primary causative factors of the disease, but only secondary settlers. The possibility of infection cannot develop from the intestine in normally composed bile. Normal bile is sterile. Normally composed bile is a product of the liver due to the influence of its secretory nerves (Pflüger). Only when these secretory nerves harmoniously induce the activity of the hepatic parenchyma, will there be a product which contains all component parts in correct proportion- yellow, clear, sterile bile. For our purpose we are especially interested in the correct proportion of biliary acid salts to cholesterin, as the former are solvents of the latter, and also represent those component parts that can resist the development of infectious germs which may have arrived there from the intestine. us assume that hepatic function is changed by an affection of the secretory nerves, causing a disproportionate overproduction of cholesterin and a disproportionate underproduction of bile-salts. There will be a deposit of cholesterin in the gallbladder, which crystalizes around desquamated epithelium, forming a nucleus, and this will be the beginning of a gallstone. Bile abnormally composed is not able to resist infection from the duodenum in the same way as normal bile; there will be additional infectious biliary decompositions which accelerate the secretion of cholesterin. There is no doubt that biliary calculi, once formed, constitute foreign bodies which easily give rise to catarrh, especially when there is a simultaneous infection. When gallstones are first formed, patients do not suffer from biliary colics, and may carry their gallstones without experiencing any inconvenience, and perhaps without knowing it. To cause trouble, some special irritation is required, and this may be assumed to come from a calculus penetrating into the neck of the gallbladder where it will settle. Occasionally the mucous membrane underneath such a calculus is found to be ulcerous. soon as matters have arrived at this stage, the pathologic condition is complete. Gradually local hyperesthesia manifests itself which in many cases leads to general nervous disorders. The mine, so to speak, is laid. Sudden fright, anger, a badly digested meal, pressure on the abdomen, a sharp movement, the shaking of a train or carriage, palpation by the physician, colds, etc., are factors apt to bring the long prepared shock to a head. Glaser observed a sign occurring at the tip

of the tongue which has become an important factor for the diagnosis. It can very frequently be noticed that the papillae fungiformes at the tip and margin of the tongue protrude in the shape of red nodules, almost the size of a pinhead, and resembling, the red seed on the ripe discus of a strawberry. Patients with this sign generally feel the attacks coming on for hours and even days. In other cases these papillae do not protrude. In such cases the paroxysms generally come on quite suddenly, require only short preparation or aura, and remind one of epilepsy.

The chologen treatment of cholelithiasis is founded upon the theory of it being prim. arily a nervous affection. The first step is to influence the secretory nerves of the liver in such a way as to restore their harmonious function, so that the hepatic secretion again becomes normal. We may then expect that no further stones will be formed and that those which have already been formed will become disintegrated. It is not impossible that this process really takes place more often than we realize without medical assistance, epsecially when patients are removed to other and more healthy conditions of life which causes the hepatic functions to become normal again. The quantity of bilesalts contained in the human bile fluctuaies between wide margius-according to Landois between 6 and 11%. The idea might be conceived, and indeed has been conceived, to select just these bile salts, sodium glycocholate and sodium taurocholate as suitable agents to dissolve gallstones. It was found that although these salts are excellent cholagogues by considerably increasing the quantity of bile, they do not better the proportion of the bile constituents in the desired direction, They increase the quantity, but do not im. prove the quality of the bile. This is unfortunately the case with most of the cholagogues. For this reason all the hopes that were placed in remedies of this kind were destined to disappointment.

A remedy such as we require should in the first place increase the specific bile components, especially the biliary acid salts, without rendering the bile thick or viscus. Furthermore, this remedy should be assimilated by the bile in order to be able to develop antibacterial and anticatarrhal effects in the bile ducts. It is also necessary that this remedy should remove any existing hyperesthesia and and hyperkinetic energy, it has to overcome the almost constant habitual constipation, and all this must be accomplished without producing any injurious effects, even after months of continuous treatment.

There is no single drug or substance which.

will produce these manifold effects, nor is there any single combination which answers all individual requirements. After hundreds of experiments Glaser has fortunately succeeded in preparing three mixtures which answer the purpose in almost all cases. But even these mixtures have sometimes to be combined with each other. They consist of mercury, podophyllin, melissa, camphor and caraway in different proportions and are made into tablets called chologen* Nos. 1, 2 and 3. In adapting the remedies to individual conditions, notice should be taken of their effect upon the movements of the bowels; the effect should be decisive, but not continuous. It is desirable to have one or two evacuations a day. The next point which requires attention is the selection of the proper tablets in such a way as to counteract colicky manifestations. The noticeably favorable effect of chologen is the great rapidity with which the gallstone colic is relieved, the patient feels better and the continuous sensation of tension and pressure disappears with the extreme mental depression which frequently exists. For the purpose of illustrating the manner of recovery in the treatment of gallstones with chologen I submit the following cases:

came on

CASE I. Mrs. B., aged 48 years, consulted me April 20, 1904. She came with a history of having frequent attacks of gallstone colic. She belched a great deal of gas, had headache and constipation. She said her stomach was sour, and she frequently tasted food previously eaten. Had lost twenty-five pounds in weight. Her painful attacks which at first once every six months were then coming every week. The gallbladder was easily palpable with a peculiar feel suggestive of gallstones and tender on pressure. An examination of her stomach contents showed a condition of hyperchlorhydria. She was given salicylate of soda before meals and equal parts of sodium bicarbonate and magnesia just after meals. She began to feel somewhat easier, but continued to have attacks of severe pain which could be relieved only by hypodermics of morphine. I advised operation for gallstones, but patient

On

refused. At this time I lost track of the case on account of my visit to Dr. Glaser in Switzerland. Upon my return patient consulted me again for her gallstone colics. September 28, 1904, she was given chologen No. 1, two tablets three times a day before each meal. This brought on diarrhea and the tablets were reduced to one three times daily befor each meal. Her skin which was pre

viously yellowish, began to clear up, and she

* Chologen tablets are prepared at the Physiologisch-Chemisches Laboratorium, Hugo Rosenberg, Spichernstr. 19 Berlin, Germany.

improved immediately. After taking chologen for three months she regained her weight, and was seemingly in good condition. She has never had a recurrent attack.

She

CASE II.-Mrs. P., aged 54 years, consulted me October 19, 1904. She gave a his. tory of having gallstone colic for ten years. The attacks came on usually at night. belched a great deal of gas, suffered with constipation, pain in the back, which ran up to the tip of the right shoulder, had been jaundiced many times. During the past two years the attacks of gallstone colic came more often. In September last the colic was attended with a yellow discoloration of the skin, dark urine and her fecal matter was of a light color. She was greatly emaciated. Liver slightly enlarged and she had a gastroptosis. The gallbladder could be easily felt and was quite tender under pressure. Patient had no appetite, was nauseated, and as soon as she ate had a feeling of fullness and desired to belch gas. Was given chologen No. 2, two tablets three times a day before each meal. November 3, 1904, there was no improvement, and on November 6th she had another attack of gallstone colic necessitating a hypodermic of morphine. 1 was inclined to the belief that this hypodermic was really unnecessary for we must remember that morphinism is not an uncommon thing with gall. stone patients. I then added chologen No. 1, two tablets at bedtime with chologen No. 2. The evacuations of the bowels were better and patient began to have a feeling of well being which she had not felt in some years. After taking chologen tablets for two months the gallbladder was not tender and patient felt comparatively well. She has greatly increased in weight and strength and has not had another attack.

CASE III. Mrs. J., aged 52 years, consulted me November 4, 1904. She had been sick for three years suffering with nausea nearly all the time. Had been constantly losing in weight until she lost forty-eight pounds. Had such severe pain after meals that she could take only small quantities of food at a time. She had attacks of vomiting and pain in the epigastrium. This pain came on suddenly and was so severe that it was necessary for her to take a hypodermic of morphine. Of late these attacks had been getting worse. The pains were of a boring character and ran through to the back. had had as many as three attacks in one week. When she first consulted me she said her appetite was quite good, but she did not dare to eat on account of pain. She complained of severe pains in the abdomen coming on at midnight very suddenly. The pain

She

disappeared slowly after having taken a hypodermic of morphine. The bowels seemed to be regular. In the right side over the gallbladder there was extreme sensitiveness to pressure which brought out a pain that radiated toward the right. She was slightly jaundiced, urine was dark but contained no bile. Could not lie on her left side without suffering pain in the hepatic region. I made a diagnosis of cholelithiasis, and on November 8, 1904, the patient was given chologen No 3, one three times a day before meals. Patient improved from the beginning. Her bowels moved daily and the tension over abdomen subsided. She began to gain in weight and was relieved from the frequent attacks of pain of which she previously complained. At the end of four weeks the pain produced by pressure over the gallbladder had entirely subsided. At the end of three months patient was as well as she ever had. been and seemingly had made a complete recovery.

They

CASE IV. Mrs. C. C., aged 48 years, consulted me November 14, 1904. Had had attacks of pain in her stomach for the past three years which were called gastralgia. These attacks had been getting worse until they came every eight or ten days. came on suddenly without any warning. She had been treated for gastralgia until her physician diagnosed gallstone colic and sent her to me for treatment. Gallstones had never been found on examination of her feces. When I first saw her she had a yellow discolored skin with a marked yellowness of conjunctiva usually found in jaundice. There was pain upon pressure over the gallbladder and I confirmed the diagnosis of gallstone colic. She was given chologen No. 2 one tablet before each meal, and chologen No.3 one tablet between meals, thus receiving six tablets a day. Her improvement began at once and at the end of four weeks she was taken with a sudden attack of gallprevious attacks. stone colic but not nearly as severe as the At this time it was not necessary to give morphine for an application lieved the patient. She was then given choloof equal parts of olive oil and chloroform regen No. 3 one tablet before each meal and chologen No. 1 one tablet at bedtime. has not had another attack, has gained in weight and is seemingly in good health. She continued the treatment for three months and is now taking chologen again for another three months, as this is necessary to overcome the chronic constitutional condition.

She

CASE V.-Miss N. G., aged 32 years, consulted me December 14, 1904. Had had attacks of gallstone colic for the past four years.

came on

For

more frequently. She felt as though a red hot iron were in the pit of her stomach. Continually got worse until she had taken a hypodermic of morphine. One week before her attack she would have pain. Bowels were always constipated. Had lost twelve pounds. December 20th was given chologen No. 3 two tablets three times a day before each meal. She began to have diarrhea and the tablets were decreased to one tablet three times a day before meals. The patient began to improve from this time, and is now in better health than she has been for years. CASE VII.-Mr. G., aged 72 years, consulted me January 24, 1905. He was always in good health until the age of 54. twenty years he has had pain in the right side of his abdomen. During the past ten years he has had frequent attacks of colicky pains. During the past year his physician called his attacks gallstone colic. He had been in bed four months with chills and fever, a temperature which would at times go up to 103. At the time he first saw me his appetite was poor and he had distress immediately after eating which would last an indefinite period. Suffered greatly from flatulency, color of feces light. Had constipation, some backache and tired quickly upon the least exertion. Slept poorly and was jaundiced. Upon physical examination there was extreme tenderness over the gallbladder. His liver was greatly enlarged. During the winter when he had fever he had consultation as to what was best to be done for his gallstones and the two surgeons and attending physician thought, on account of his age

and weak condition, that it was better not to operate. On January 30th patient was put on chologen No. 3 two tablets three times a day before meals with chologen No. 2 two tablets at bedtime. chlorhydria he was given an alkali after On account of a hypermeals. His bowels which were previously constipated began to move better. tacks of boring pain, which felt as though His atthey were going right through the vertebrae, began to cease. gradual and continuous until February 20th His improvement was he was taken with chills, fever and pain which subsided after an attack of vomiting. Since then his improvement has been continuous. July 10th he went East to attend a convention apparently in good health. He is still under treatment and constantly improving.

CASE VIII.-Mrs. F. L., aged 44 years, consulted me February 20, 1905. Suffered from gallstone colio for four years. Between attacks patient was practically well. She was anemic and badly nourished. The pain for a long time was supposed to be appendicitis. The tenderness of the gallbladder, jaundice and localization of the severe pain during the attacks made a diagnosis of gallstones quite positive. She complained of a bloated feeling and belched a great deal of gas. She was placed on chologen No. 3 two tablets three times a day before each meal and chologen No 1. two tablets at bedtime. improvement began at once and she is now in a very much improved condition.

Her

Aside from the treatment with the various chologen preparations it is advisable to eliminate the cares and worries of daily occupation. Considering that cholelithiasis is in the main a nervous disorder, it can be easily understood that the constant excitement and vicissitudes of modern high-strung life hinder rather than aid the effect of medical treat. ment. It is a well-known fact that exercise in the open air, combined with repeated deep breathing, produces a decidedly favorable influence upon the functions of all organs, notably that of the liver. The accelerated circulation of the blood, the profound breathing and the increased ascending and descending movement of the diaphragm promote the preparation and secretion of bile. The diet should be carefully selected as long as there are inflammatory conditions in and around the bile ducts. This means that only small quantities of easily digestible substances should be eaten at a time, and that these should be slowly and thoroughly masticated. A mixed diet, in which meat and vegetables also find a place, is one of the most excellent means to increase hepatic function.

Lob

ster, salmon and raw fruit should be exoluded. The principal thing is thorough mastication of regulated quantities, but no starvation.

With my experience in the treatment of gallstones with chologen, I agree with Glaser, Meyer, Winterberg, Siegmann, Fränkel, Jacoby, Margoniner and others in that the treatment with chologen should be tried before resorting to surgical measures except in cases of empyema of the gallbladder, perforation, general infection, abscess of the liver, extensive inflammatory adhesions or malig. nant neoplasms. After surgical operation chologen is indicated to disintegrate the small stones lodged in the bile ducts and influence the bile so that it will exert its healing effect upon all catarrhal conditions.

It is necessary to study each case carefully so as to be sure that each patient is taking the proper quantity and to take each individual into consideration just as we do in the administration of other remedies. I feel convinced that chologen will find a welcome place in our materia medica for the treatment of gallstones.

32 West Adams Ave.

BIBLIOGRAPHY.

Robert Glaser-Muri. Die Heilung der Cholelithiasis durch Chologen und Bericht uber meine ersten hundert behandelten Falle. Correspondenzblatt f. Schweizer Aerzte 1903, No 3.

Haberlin, Zurich. Cholelithiasis. Chologenbehandlung. Operation. Correspondenzblatt f. Schweizer Aerzte 1903, No. 23.

Robert Glaser-Muri. Zur Behandlung des Cholelithiasis. Correspondenzblatt f. Schweizer Aerzte 1903, No. 12.

Siegmann, Wien, gew Sekundarazt am k. k. Krankenhaus Wieden. Zur internen Therapie der Cholelithiasis. Aerztl, Central-Zeitung 1904, No. 1:-12.

Meyer, Gerichtsass. und Bahnarzt, Bernstadt, Das Wesen und die Behandlung der Gallensteinkrankheit. Allgem. med. Central-Zeitung 1904, No 2.

Jos Winterburg, emer. Assistent d. III. ‚ed. Abteilung,des k. k. Allgem. Krkh. Wien. Neuere Beitrage Zur Behandlung der Cholelithiasis mit Chologen, Wiener klinische Rundschau 1904, No. 19.

Gaudin, Paris. Guerison de la Lithiase biliaire par le Chologene. Le Progres medical 1904, pag. 156-157.

J. Margoniner, Berlin. Ueber Behandlung der Cholelithiasis mit "Chologen" (Glaser).

Suzor, Paris La cholelithiase et le chologene. Les nouveaux remedes 1904. No 4.

Rob. Jacoby, Berlin. Meine Erfahrungen mit "Cologen" (Glaser) bei Gallensteinerkrankungen. Fortschritte der Medizin 1904, No. 14.

M. Frankel, Berlin. Die interne Therapie der Cholelithiasis mittelst Chologen. Berl. klinisch-therapeutische Wochenschrift No. 37-40, 1974.

Manfred Frankel, Berlin. Zur internen Behandlung des Cholelithiasis mit Chologen- Die Heilkunde, Juni 1905.

MISSOURI STATE MEDICAL ASSOCIATION. A most interesting and profitable meeting of the State Society was held at Jefferson City on May 15, 16, 17, the sections being well attended. After a strong session in the general meeting on Thursday morning, Dr. C. H. Wallace, of St. Joseph, was elected president. A full report of this meeting will ap pear in our next issue.

I would be glad to learn that they intend to study our Western crime-jurisprudence, and thus get rid of their fearful system of torture. Just think of the horrible picture of the "Lintze" execution, which is borrowed from China. I have photographs of this kind of capital justice taken by my brother, who is chief engineer of the Canton and Hankow railroad. They represent the cutting into "thirty-six" pieces of a living victim. The executioner first gouges out, or crushes the eyeballs of the poor wretch tied to a bamboo cross. Two assistants stand one on each side, with huge fans to ward off the arterial spoutings, while a third assistant is represented on hand, with an armful of freshly sharpened knives. The cheeks are cut off, the breasts sliced off, then the biceps, triceps, gluteals, thigh muscles, calves; the dismemberment commences from the hands, and then the feet up to the trunks. As last cuts, a knife is run through the heart and the head cut off.

The last thought in civilization of the Japanese I think will be improvement of their cruel Chinese justice, which they still hide from the prying eyes of Westerners.

The remark of Lord Salisbury twenty years ago, speaking of Port Arthur, "Russia has got nothing," is verified. Russia should have put her household in order before going abroad into Manchuria. Even now in the hour of humiliation her execrable autocracy and the subservient hierarchy do not see that which is plain to the world, the necessity for internal reform and the riddance of the state from the large remnant of feudalism.

I must confess that my sympathy is with its people, and not with its rulers. The dom. inant class, living a life of luxury, frivol

*The first paper of this series appeared in the MEDICAL FORTNIGHTLY issue of April 25, 1905.