method I shall describe that I can not use language strong enough to outline its advantages over the method usually advised in text-books and elsewhere. It is a method which I have employed in two cases. I have only operated three times upon the common duct, and in the first operation I found it one of the most difficult that I ever encountered, especially in trying to suture the divided duct. I remember to have gone down carefully and isolating the portal vein as well as the hepatic artery, and coming to the duct I incised it parallel with its course, and succeeded in removing the stone fairly well, but the difficulties encountered in suturing the duct, with the wound so deeply situated, were almost insurmountable; the duct could not be drawn forward in the least, and I confess that I was not sufficiently skillful to suture it well. The patient died a few days after the operation. I take it there was probably some extravasation of bile, but she died really from hemorrhage; she had been profoundly jaundiced for a long time, probably eight or nine months, and subsequently died. The next case in which a stone was removed from the common duct I reported to this society four weeks ago, and you will remember I spoke of incising the gastrohepatic omentum vertically for two or two and a half inches. This was in a very much more difficult case than the first one, on account of the extensive adhesions which had formed, but the effect of the method of incising the gastro-hepatic omentum was to allow the duct to be. brought forward fully half the distance of the wound. By incising the membrane vertically instead of transversely it allows the duct to come forward two and a half to three inches, and it is then an easy matter to apply the sutures. In the case reported to-night the same thing occurred; with forceps I picked up the edges of the long incision, being careful to get over the portal vein and the hepatic artery, pushing them out of the way with my finger, the duct coming forward much further than by any other method. I know there is nothing original in this, but no mention is made of the procedure in text-books so far as I know. The usual advice is to incise the mesentery parallel with the duct, and after pushing it aside then incise the duct itself. By this vertical incision it gives much more room, and little dexterity is required to suture the incised duct, of course using several pairs of hemostatic forceps to bring the duct nearer the surface and getting the finger beneath it. By this means it can be sutured so tightly that I would feel little concerned about dropping the duct back and closing the abdominal cavity, if of course I had a wound in the gall-bladder to lessen the ten

sion on it. This method of incising the gastro-hepatic omentum and the duct simplifies matters very much; there is less danger of wounding adjacent structures, the vein and artery, and it renders application of the sutures much more easy.

Discussion. Dr. W. O. Roberts: The suggestion Dr. Cartledge makes with reference to the incision strikes me as being a very good one.

Dr. A. M. Vance: In regard to faceting where gall-stones are in the bladder: I had a case some time ago where twenty-three gall-stones were removed, and none of them were faceted as we ordinarily find them, but they were shaped like little jack-stones; masses of them were fitted together in such way that faceting could not occur.

Dr. J. B. Marvin: An important question in this connection is the composition of the stones: The composition of the stones may account for the fact that they are not faceted. When formed of cholesterin they are soft, and faceting easily occurs. I think Dr. Cartledge is correct that these stones may form in the cystic duct. I have seen small stones up in the minute ducts of the liver. I have a liver at the present time in which you can hardly make a section of it on account of calcareous deposits all through it turning the edge of the knife. Another point, faceting sometimes depends upon the amount of fluid in the gall-bladder; with plenty of fluid in the gall-bladder, they might roll around each other so that faceting would not occur. These stones look like the ordinary cholesterin formation. Such calculi are sometimes formed of soda salts or lime salts.

The essay was read by Frank C. Simpson, M. D. Subject: "Observations on Interstitial Nephritis, etc." [See page 125.]

Discussion. Dr. J. B. Marvin: I differ very much with the essayist as to the etiology of interstitial nephritis. If he had looked a little deeper beneath the surface, he could probably have accounted for many of these cases in women at the menopause-the nervous phenomena at this time may be due to many causes; interstitial nephritis is most probably only a coincidence. It is true the majority of these cases occur in old people, though I have seen well-marked cases in quite young people. I think heredity plays a very important part in this class of troubles. I have been peculiarly fortunate in one respect, in having had opportunity to see three generations, the grandparents, children, and grandchildren, in which this trouble prevailed, and have

spoken several times before this society, and also the Kentucky State Medical Society, upon this point, and think it well worth bearing in mind. Back of heredity there is another feature which must not be forgotten as a causative factor in these cases, viz., gout or lithemia. Other things that have to be considered are lead poisoning, malaria, syphilis, alcohol, and mental worry; but certainly the gouty or uric-acid tendency is an extremely common and potent factor in the production of these troubles, and is one reason why they occur later in life. There must be some toxic or poisonous agent circulating in or through the kidney that would cause such change in the blood vessels or connective tissue of the organ. The disease is not confined to the structures of the kidney; it is widespread, involving the entire arterial system, and it is probably true that mental worry, anxiety, and business cares also act as causative factors, not only in women but in men, far more frequently in men than in women. The disease, in my experience, has been found much more common in men than in women, and the reason for it is mental worry, business anxiety, and care in a person leading a sedentary life, and perhaps a little over-indulgence at the table, and having also perhaps a uric-acid or gout tendency—in these you have the cardinal principles almost certain to eventuate in this trouble unless the patient is extremely careful in his diet and habits.

I believe the disease is essentially chronic, and also think it may be recognized earlier than the essayist would seem to indicate. It is true in some cases such as he refers to, we are called in at the close of the chapter, just about the time when the patient is going into coma or convulsions. But in cases that have been watched, where we know something about the family history, I think we are competent to make a diagnosis a great deal earlier than he states. The high-tension pulse, with of course an increased flow of urine of low specific gravity, is always indicative of this trouble. You need not find albumin or casts. all the time, but a low specific gravity, increased quantity, a hightension pulse, a pulse that will take three fingers to obliterate, with an accentuated second beat, you have almost an absolute certainty as to what is the matter, and if you will take specimens of the urine at different times in the twenty-four hours you will find some albumin. and occasionally a tube-cast. The urine is generally strongly acid, and patients complain of smarting in urethra. That albumin and casts are not found in the urine of these patients I believe to be due to faulty examination, for instance getting the patient to pass urine (as is

required by life insurance companies) in your presence; or in getting the urine after a night's rest you may not find either albumin or casts, but if you will take a sample of the urine after the patient has taken some exercise or has done something which will cause a little more wear and tear on the system, you will nearly always find albumin and occasionally tube-casts, especially if you will use the centrifuge. Take a low gravity urine and let it stand for some time, as most people do before an examination, and putrefactive changes will occur so quickly that all the tube-casts will be destroyed and you will find none in the sediment. With a small sample of urine from the vessel, in its fresh state, by means of the centrifuge the sediment can be immediately precipitated, and you will get casts that would have otherwise been overlooked. I do not believe we are justified in saying that the urine does not contain casts unless we use the centrifugal machine in making our examination. They are sometimes scanty, possibly hyaline, but generally granular, small tubes which float and will not go to the bottom unless forced to do so by means of the centrifuge. By the use of this little instrument, if the urine contain casts, even few in number, they can be detected.

Upon another point I have had a different experience from the essayist, and that is in regard to the gastric symptoms. These in my experience have been very common, and I think Dr. Simpson has made himself misunderstood in this particular. He refers to the coated tongue, foul breath, and the usual phenomena that go along with this trouble, but he is not inclined to attribute these phenomena to gastric trouble. With a patient who is past middle life, with a coated tongue and foul breath, complaining of dyspepsia, especially if it be the so-called nervous dyspepsia, palpitation, various disturbances about the head, flushed face, numbness of the fingers, the so-called dead finger, dead hand, etc.-that is part of the gastric phenomena, and you can call it nervous dyspepsia or what you choose, it is one of the worst of all the phenomena that you meet in these cases before coma begins to

come on.

In regard to dyspnea: Asthmatic symptoms are very common, so extremely common, in fact, that I have always thought of kidney trouble in connection with it. Of course I refer to asthmatic symptoms where all other causes were ruled out, such as polyps of the nose, hay fever, etc., cases in which there was no adequate cause for it except kidney lesions. You will find sometimes, in addition to the

asthmatic symptoms, the patient will have a peculiar sighing respiration; the patient will also tell you that he is a little "short-winded." This is very common in kidney troubles. It has been so common in my experience that I always think at once of kidney trouble. I do not wait even for an examination of the urine.

In regard to the treatment: I believe that more can be accomplished by the administration of drugs than indicated by the essayist. Certainly he is correct that most can be done by a regulation of the patient's diet and his habits, and I believe these patients are better sent away from a climate like this. This climate is very detrimental to patients with that kind of kidney trouble. If you go northeast along the seaboard you will find the trouble is more prevalent there than further south or in any equable climate or one less subject to sudden changes. In the regulation of diet I believe we have made grievous mistakes sometimes in trying to follow too hard and fast dietary lines that have been given by writers on the subject. As to the milk diet, theoretically it is all right, but practically you have to make many exceptions to it or you may do harm. The general condition of these patients is below par; the whole system is poisoned; the disease is progressive, and the kidney disturbance is only an effort of nature to eliminate the poisonous products, and if elimination can not be secured. through the kidneys it must take place through the skin or bowels, through the respiratory tract, and we are very liable to have phenomena referable to one or the other of these tracts. The patient is being poisoned, and if you give him a strict milk diet the condition of the system is still further debilitated because of insufficient nourishment, and he is often made worse. I believe we ought to give more fats, certainly more of the starches, and I do not withhold eggs nor a moderate amount of meat, especially white meats and fish. If the patient were large and fleshy I could cut down the meats more than I would if he were thin and sparely built, and vice versa.

Another point, and I make this almost a certain guide to me in the administration of remedies, I believe these patients are made worse by any thing that tends to increase the tension of the circulation or stimulate the heart. Tobacco, alcohol, tea, and coffee should be prohibited.

How can we explain that mental worry and anxiety should cause a trouble like this? If it is primarily dependent upon the entrance. into the circulation of certain toxic agents, chemical or bacterial, how can we explain the condition except to say that it is primarily mental?