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security in their formation in the bile ducts. This is what happened to several cases in Kehr's experience. Every medical Cialis 20 Mg Quanto Costa man must, of course, feel that a great responsibility is incurred when he is called upon to advise his patient to refuse or submit to operation. If the disease has advanced considerably, to decline operation may mean a long jxiriod of se- vere recurring pain with the risk of perforation or serious septic mischief which will in all likelihood sooner or later prove fatal. On the other hand, op- eration may mean death or only a very temporary relief from the intolerable agony of this disease. It is now more than thirty years ago that Mr. George Drown, a general practitioner of London, operated for gallstones, but it is only within the past fifteen or twenty years that the operation has become fa- miliar to surgeons and inedical men. In the early days of its history the successful cases published by Lawson Tait and Mayo Robson aroused great expectations and made a deep impression on medi- cal men as well as the general public. Though these operations have not yet been proved to be without danger nor an absolute safeguard against the recur- rence of the Cialis 20 Mg Quanto Costa symptoms of this disease, yet the belief in the efficacy and advisability of operation in many quarters is so strong that medical men have felt uncomfortable when they could not make up tlieir minds to advise their patients to submit to opera- tion. Considerations such as these should, I think, weigh somewhat with the surgeon who blames the medical man who clearly sees the serious issue in- volved in operation and does not abandon all hope of relieving the patient or even accomplishing an absolute cure by other means. Dr. H. P.. Anderson (i), of Toronto, admitted that while surgical procedure was frequently ihz best, and often the only means of offering a chance of relief, its advocacy based on certainty of cure and assurance of nonrecurrence was unwarranted. The main object of treatment was the relief of the in- fection and infi.amniation and not merely the re- moval of the gallstones. This not infrequently oc- curred under nonoperative treatment, especially, in early and mild cases and particularly after first at- tacks before serious local damage had been done by the infection. Medical treatment should be fully carried out in all cases where the patient's physical condition did not warrant operation and in the nu- merous cases in which operation was refused. It should be emjiloyed in many cases as a i)reliminary to operation in order to allow the acute infection to subside as far as ]iossihle. It should be carried out in all rases after operation to prevent reinfection and recurrence if possible. He never advised strongly against operation in any case, unless an operation was definitely contraindicated because of the patient's physical condition : but after explain- ing the ])ossibility Cialis 20 Mg Quanto Costa of failure and that operation might eventually be required, he did not Cialis 20 Mg Quanto Costa hesitate in early or mild cases or after first attacks Cialis 20 Mg Quanto Costa to give medical treatment a thorough trial, and this course in many instances gave excellent results. Doctor Roessel pointed out that gillstonc patients were first treated by tiie physician and by him often re- ferred to tlie surgeon : the surgeon, however, rarely after ojicration turned the patient over to the medi- cal man again for subsequent treatment. In Ger- many it is the custom for the Cialis 20 Mg Quanto Costa surgeon to turn the 934 WEISS: GALLSTONES. patient over to the physician after operation for medical treatment and care. Instances had occurred where faikire to provide this care had been attended with undesirable results. HISTORY. Gallstones were first observed in 1565 by Johann Kentmann, of Dresden, who communicated his dis- covery to Conrad Gessner, to be made use of in his great work on Fossils. According to Marcellus Donatus, they were likewise found about the same time by Tournamira and Gentilitis. Biniviene, Vesa- lius, and Fallopius examined and described them with great care, so that in 1643 Feruel was able to treat in detail their characters, causes, and symp- toms. Glisson also contributed to the history of these concretions. As regards the pathology and diagnosis of gallstones, the work of Friedrich HoiT- mann, of Halle, was of far greater importance than any that preceded it. Bianchi and J. B. Morgagni recorded numerous fresh observations which greatly increased the information upon this subject. A similar remark applies to Boerhaave and Van Swie- ten, and likewise to Sydenham and Sauvages. For the Cialis 20 Mg Quanto Costa first accurate investigations into the structure ot gallstones, we are indebted to Fr. August Walter, who carefully described and figured the rich collec- tion in the museum at Berlin. To this work, the works Cialis 20 Mg Quanto Costa of Sommering, Prochaska, and especially H. Meckel deserve to be added. The first chemical ex- amination of gallstones originated with Galeatti, but led to no result. It was not until after the dis- covery of cholesterin that Fourcroy and Thenard succeeded in determining anything certain as to their composition. Bramson, Platner, Hein, Seifert, and liouisson have been more especially engaged in the chemical analysis of these concretions. As re- gards the pathology, diagnosis, and treatment Cialis 20 Mg Quanto Costa of the forms of disease produced by gallstones, it is scarcely possible to review the medical literature. The most important observations have been col- lected by Fauconneau-Dufresne, in his Traite' de raffcction calculeusc dit foie et dii pancreas, Paris, 1 85 1. Europeans have found gallstones in from five to ten per cent, of all autopsies; in the East, On the contrary, they are extremely Cialis 20 Mg Quanto Costa rare, only one or two cases are recorded. ETIOLOGY. The formation of gallstones, whether in the ducts or in the gallbladder, may be considered under two heads : i, immediate or exciting causes ; 2, disposing factors. Immediate or exciting factors. — The immediate cause of the production of calculi is a mild form of