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demonstrated their value. To many, the use of olive oil made an .appeal during some time as hav- ing the power to dissolve gallstones, and for this reason it was given — at the present time it is not believed in. It is true, as has been shown by Har- ley and others, that gallstones may be rapidly dis- integrated by contact wdth olive oil in a test tube. It is also probable that perfectly healthy bile has such an eft'ect in a moderate degree. But if we realize the improbability of any direct contact with biliary calculi when olive oil is taken by the mouth, it lessens our belief in its utility. Moreover, when calculi are present in the gallblad- der, the walls of the gallbladder are already more or less diseased. Of course, it must be understood that no med- icinal treatment will effect an absolute cure of gall- stones. It may soften them and diminish their size, possibly, in some instances, sufffciently for them to pass through the biliary canals and escape through the intestine. Yet we know in how few instances such stones have been found after the most careful examination of the stools. When we first discovered what we believed to be Buy Nortriptyline Online biliary stones, a later chemical examination proved that they were not, but simply the oil combined with mucus and salts. In considerable doubt Order Nortriptyline Online as to the existence of gallstones, x ray examinations may oc- casionally fix the diagnosis. But this is only true where there is a lime coating to the stones, which enables the operator to get a satisfactory picture. In all instances of pure cholesterin stones, such a picture cannot be obtained. It has been lately shown, however, Nortriptyline 25 by a special technic for making Rontgen plates and new methods of interpretation, that gallstones may be detected more frequently than formerly (3). In such cases, l^fahler Nortriptyline Mg claims that adhesions between the gallbladder and the stomach, or duodenum, may be recognized by means of the Rontgen rays. Admitting this, such recog- nition must be liable, as I believe, to much error of interpretation. Nevertheless, if in view of the frequency of these adhesions, when there is disease of the gallbladder with gallstones, the pylorus and duodenum are re- tracted toward the liver, or the duodenum is sten- osed or carried to the right wall of Nortriptyline 25 Mg the abdomen, there would be good reason to affirm their pres- ence (4). While it is often a fact that gallstones are pres- ent when a patient has been treated for a stomach disease which did not exist, it is equally true that many conditions which have given symptoms of gallstones, have not been recognized until an Nortriptyline 10mg explor- atory incision revealed them. These notably, are adhesions around the gallbladder, or connecting it with the pyloric end of the stomach, also certain forms of appendicitis, cirrhosis of the liver, and ulcer of the stomach. As to special symptoms, we know it is not infre- quent to have hyperchlorhydria, which is dependent not upon stomach conditions, but upon those pres- ent in the gallbladder and bile ducts. Even the symptoms in general, indicating some stomachal disease, may be sadly misinterpreted. In connection with this subject I would cite from a very late and admirable article of Dr. John G. Clark, of Philadel- phia (5), Doctor Clark writes: "When the upper abdominal symptoms are vague, the ratio of inci- dence is greatly in favor of the gallbladder as the seat of the trouble. In our cases the ratio is 100 to one. In doubtful cases the diagnosis should in- variably be cholelithiasis, or cholecystitis." We should Nortriptyline 25mg therefore be on our guard as far as possible against such errors, and it is only the sever- est, most critical examination of the patient's his- tory and symptoms, which \y'\\\ enable us to avoid not a few mistakes in diagnosis. In women, espe- cially, who have been pregnant more than once, in patients who have had typhoid fever latterly, we should be more suspicious and careful. In men who eat, and drink freely ; who take much beer, or any alcoholic stimulant; who also lead sedentary lives, and who have Cheap Nortriptyline many cafes and worries, if they are over forty or fifty years of age, we should ever be alive to the probabilities of the case. In many instances our diagnosis may be confirmed by an attack of jaundice of some duration, and also by the lack of bile in the stools, but such a condition, as we know, may often be w^anting and later we have indisputable evidences of gallstones. It is now admitted that death rarely occurs dur- ing an attack of biliary colic. It is also true that surgeons do not believe it to be good practice to operate during such an attack, unless it is impera- tively required by grave complications, such as gen- eral infection or spreading peritonitis. On the other Buy Nortriptyline hand, whenever the attacks of biliary colic have been repeated, or the symptoms Nortriptyline 10 Mg have become more continued and graver, an operation must not be too long delayed. Among the very fatal sequels which often follow too long delay in operating, we should note the development of cancer of the blad- der or gallducts. Three such instances have been reported lately by Dr. James Tyson, of Philadel- phia (6), and from them he deduces the importance June 5, 1915I KOJiJXSON : GALLSTONES. 1 143 of early operation with a view to their prevention. I admit, therefore, the advisabihty Generic Nortriptyline of not waiting too long. On the other hand, 1 deplore all opera-

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