Gallstones discussion
It is a well-known fact that autopsies frequently reveal the presence of gall-stones which during life never gave rise to any symptoms. This is important for the reason that it leads to the observation that as homoeopathic physicians we do not treat gall-stones, but only patients who may have them. The diagnosis of their presence by the ordinary methods is frequently very difficult, if not impossible, and even during an attack of so-called gall-stone colic we have to be careful in our diagnostic differentiations. Since, however, the diagnosis of gall-stones is not intended to be within the province of this brief essay, no more will be said upon this point, except to mention that expert radiography is the one and only certain diagnostic measure outside of an exploratory laparotomy.
The object of this paper is to show if possible, how much can be expected of homoeopathic therapy in cholelithiasis and when this therapy should cease to be applied. Given a patient whose history shows an undoubted attack of gall-stone colic, our efforts are directed at the patient himself and not at the supposed or alleged, or even actual presence of stones in the gall-bladder. This means that the patient is to be prescribed for in the usual Hahnemannian way, careful casetaking being of the greatest importance; it also means that all legitimate hygienic, dietetic measures be applied and that proper exercise be invoked. Treatment carried out according to this idea has many times been apparently successful, yet it must be admitted that even without any such treatment, patients are known to have lived on without any return of an original attack of gall-stones. In other cases, patients have had no return of trouble for years and have then been seized by a most violent and at times even serious attack. Hence, we must not be too ready to conclude that, because a patient has remained free from trouble for even a long time after our best therapeutic endeavors, the credit for this happy state of affairs belongs to us.
An acute attack of gall-stone colic can be relieved by a well-chosen homoeopathic remedy, particularly when given in high potency and provided that the patient presents, or is in a condition to present, intelligent indications for a remedy. There can be no question about this statement on the part of the Hahnemannian prescribes who knows the signs of curative action of the remedy, properly given. Others may and do insist that any relief obtained after the administration of such a remedy, is purely accidental or a matter of coincidence. We have no sympathy with this view, but on the other hand it must be admitted that our best efforts do at times fail. They fail in those cases in which we are unable, no matter what the reason may be, to obtain clearly defined symptoms on which to base the selection of a remedy, or for mechanical reasons. Under such circumstances our only recourse is to employ the well-known, extra-homoeopathic palliative measures, to be found in physiologic medication. Nor should we hesitate to employ the latter from any sense of a betrayal of principle, since after all the real physician concerns himself first with the best interests of his patient and then thinks of his own interests afterward.
Not all cases, however, of cholelithiasis, no matter how treated, terminate happily. In a goodly number, especially those in which the acute attacks of pain have been intermittently persistent for several days, followed by severe jaundice, he danger of impaction of the stone in the common duct, followed by cholangitis, must be kept in mind. Ulceration is then apt to ensue and of course pus formation immediately takes place. Or, the stone may become lodged in the cystic duct, leading to a distended or dropsical condition of the gall-bladder or to an acute inflammation, at first catarrhal but later suppurative, a true cholecystitis.
In any of these cases, surgery is very likely to be required and will be immediately imperative if signs of perforation or of abscess formation show themselves, such as severe pain, nausea and vomiting, chill, fever and sweat, an increase in the leucocyte count above twelve or fifteen thousand. It is then that most excellent results may be looked for by a combination of good surgery with painstaking homoeopathic prescribing, the former however being of the greater importance in this instance. One of our most reliable indications for the employment of surgery, and this applies to other conditions as well, is the fact that after the apparently well-chosen remedy has been given, even though the patient may be more or less relieved of his pain; pulse, temperature, blood count and diagnostic symptoms continue to indicate advancing trouble somewhere. The quicker we then turn to surgery the better for the patient, as a ruptured abscess in the peritoneal cavity is scarcely a condition to be trifled with.
On the other hand, we find cases of cholelithiasis which give a history of repeated acute attacks of hepatic colic, together with other symptoms of increasingly poor health, in which our best endeavors with carefully chosen remedies will be in vain. These cases need the knife and will get well only after they have been operated upon and the stones, frequently very numerous and often of large size, have been removed.
From the standpoint of Hahnemannian philosophy, such cases may be said to represent the tangible end-products of disease, themselves capable of creating further trouble, often most serious. But end-products are rarely amenable to medicine, which at best has a temporary palliative action only. Such cases should have been cured long before the end-product was produced, and at a time when the pathology of the case was still largely functional in character, always bearing in mind, however, the caution that perverted physiology means pathology and pathology means not only functional change, but organic change, however slight, as its starting point.
Again, we must remember that cases of hepatic colic occur in which no jaundice appears and in which no stones are found in the stools, even after the most diligent searching. These are cases in which either the stones have settled back in a diverticulum of the gall-bladder and have therefore produced no obstruction, temporary or otherwise, or they are cases where very small granules, intestinal sand, have been passed. Such very small stones are however, capable of producing severe pain by provoking spasm of the structures through which they are endeavoring to scratch their way.
In conclusion, we wish to affirm that the subject of gall-stones thus briefly treated, from the standpoint of the Hahnemannian prescriber, has by no means been exhausted and that furthermore, the thoughts expressed are based upon a fairly large personal experience with gall-stone disease. We wish however to emphasize the thought that, for the Hahnemannian physician, it is necessary to be mindful of the possibilities of this disease, of its diagnosis and of its pathology, of his own limitations which are placed upon him by the just arid natural boundaries of his art, and of the fact that because surgery must so often be called upon, he has not necessarily failed in his well-intentioned efforts. It is hoped that a full discussion will extend and amplify the several thoughts suggested, or intended.
Dr. Baylies: In many surgical cases a homoeopathic prescription is required and the surgeon should be qualified and willing to make it. If the homoeopathic physician be jointly in attendance he will of course relieve the surgeon of that duty.
Dr. Rabe and other members have spoken of cases of gall-stones, some of which were very chronically affected.
I have been treating one at occasional intervals for about a year, who has had attacks beginning in girlhood, and since womanhood often extremely severe; the pains in the gall-bladder, epigastric zone and inferior angle of the right scapula indicated, and were much benefited by Lycopodium. Pulsating pain at the lower angle of the scapula palliated by pressure, was relieved by Natrum muriaticum. Under homoeopathic treatment she has greatly improved, and attacks have been seldom and slight. She is not well, but I expect that possibly before she dies, she will get well.
These cases seem parallel to the "ups and downs of Lot Wyman."
Dr. Stearns: Dr. Becker mentioned the X-ray. Some gall-stones can be diagnosed by this means while others do not show as they are transparent to the X-ray. If they contain enough mineral substance to demonstrate their existence, they can be diagnosed.
Another point has to do with the natural history of the stones after they are formed. They give trouble, - then no trouble ensues for a long time, and yet gall-stones remain. I am thinking now of a case under treatment that was demonstrated by X-ray. She had numerous attacks of gall-stone colic, but after receiving Nux vomica for one of her attacks, she did not have another for five years. On the other hand, the gall-stones remained and I don't know whether she will be cured or not, but the remedies do not seem to influence the stones, in this particular instance.
Dr. Hutchinson: I was interested in this case before the development of the gall-stones. We get a good many such cases. On the other hand, we get a good many cases diagnosed choiecystitis and then have a very nice case of gall-stones to deal with. With the gall-stone diagnosis we may prescribe as carefully as we can and finally conclude that perhaps, after all, we did not have much of a case, but we have had a chance to enter a very good wedge even if it was only choleangeitis. Some of these cases have not had much illness at all; perhaps they have had no Homoeopathy, and we have an opportunity to teach the patient something about his health which he had never known before. We keep a case under observation and we find that there are more details in connection with it than seemed at first possible connected with the cholecystitis. I think this is a very important thing to consider always in these cases. Sometimes in a poorly developed gall-stone case we are not able to do much; at least we are not sure of it. Sometimes we do a great deal, and here, as in all homoeopathic work, the combination of disorders is most interesting.
Dr. Franklin Powel: Concerning the matter of recurrence of gall-stones I may say that I am carrying some gall-stones around with me and have for the past sixteen years. Fifteen or sixteen years ago I had frequent attacks of gall-stone colic but since that time I have had none.
Dr. Boger: This is rather a large subject and is one which has no doubt given us all something to think about. The most striking thing to me, has been the recurrence of gall-stone colic after many years of supposed cure. I recall two cases which recurred and promptly died; one, supposed to be cured eight years ago, and the other thirteen years ago. I did not see either of them in their last illness, but they died within a few days. They had been carrying these gall-stones around with them (or possibly more added to them) in addition to the ones supposed to have passed at the time they were thought to be cured.
Cholelithiasis, due to the gall-stones, is a very dangerous condition. A few cases of this kind were controlled completely by Lachesis. These patients remain well today so far as I know. Undoubtedly very large gall-stones may be passed.
Dr. Boger: I have seen two wonderful recoveries of the inflammatory condition after the passage of the stones. There was pus formation and persistent vomiting, for days and days. One case which was diagnosed gall-stones by several physicians upon operation turned out to be simply a spasmodic contraction of the gall bladder.
Dr. Stearns: I would like to ask Dr. Boger if in his use of Lachesis he cures the gall-stone condition so the concretions are dissolved, or if he only cures the colic during the passage of the gall-stones.
Dr. Krichbaum: I wish to commend the paper. Dr. Rabe wrote a much better paper than I thought he could. He clearly describes the dividing line between the medical and surgical but we forget, most of us, that after a case of gall-stones you have a sycosis to handle and you have got to keep up your treatment for years and years to eradicate the sycotic condition before you are going to get rid of the gall-stones. I remember sending a patient for X-ray examination two or three times before and then finally they decided he had gall-stones as large as a hen's egg. After two weeks' treatment they were all gone. There have been no symptoms since and it is now four years; no pain, and no symptoms after two weeks' treatment. Marvelous prescribing! We forget, a great many times, our diagnosis, and we get off on a tangent and believe we make marvellous cures when the diagnosis was all wrong, but I have never yet had a case of gall-stones that I did not cure. Now I know that I do not have all the cases and I have not had these cases which are saturated with pus conditions but I have had case after case where I know there were gall-stones and they have been cured after treatment. There is one remedy which I have had, it was handed down by an old-school man who had never lost a case, and it has been guarded in that family for over sixty years, but I got on the inside and got the Treatment. Now I am going to try it. I remember one case I prescribed for and relieved, and the gall-stones were as large as those oldfashioned one-cent pieces. When I was away last year at the meeting he had another attack, and when I saw him he got this remedy; gone in three days - Hydrangea.
Dr. Patch: I want to express my interest in this paper.
It is a very vital subject and I imagine that my experiences have been similar to those of most of us who have seen any number of cases of gall-stone disease. I remember, twenty years ago, having a very severe case which had frequent attacks (before the advent of the X-ray, of course). I was in the habit of spending a good part of the night every few weeks giving Chloroform to allay the pain. It seemed the only way that it could be overcome. No remedy that I could select gave relief during the attacks. Later Lycopodium over a long period did accomplish great results apparently. Another case went over ten years without any attack whatever; I took it for granted that she had entirely recovered, but after this time another attack came on, much milder in form, which yielded to remedies readily, and she has had no further trouble.
I have been very much interested in the diagnosis of gall-stone disease and within the past few years haye seen quite a good many cases where we have used the X-ray and the results have been very unsatisfactory. We have had two or three cases where gall-stones had been diagnosed by X-ray but under operation they did not prove to be present. In one instance, the patient was operated on about a year ago, and the gall bladder was filled with a viscid, dark and heavy fluid, but no stones. Operation, in this case, had absolutely no beneficial effect. Another case, several years ago, where gall-stones had been diagnosed by the X-ray, was operated on, and no gall-stones found, but the patient had no subsequent attacks of pain. This case too, I believe was a neurosis. Prescribing had nothing to do with it. The case was not one of my own but was seen in consultation.
On the other hand the X-ray does not always reveal stones when they are present, and the reason for this seems to be a matter that is not entirely clear, but, as has already been suggested, is probably dependent on the chemical composition of the concretions. I have come to resort to surgery where I see these cases in consultation because it is practically impossible to accomplish anything in homoeopathic prescribing unless it is done over an extended period, and with an opportunity for thorough observation and conduct of the whole case; I have seen some brilliant results and I think this method preferable to that of allowing patients to go on with indifferent prescribing, getting the indifferent results which are sure to follow. I have seen no serious results from operation when it has been performed under suitable conditions. In one or two instances, where patients have been very old, they have not recovered. I recall one case operated on for gall-stones five or six years ago, successfully, where they developed a second time. The patient did not recover, but it was due to her age rather than to any difficulty with the operation.
Dr. Powel: I would like to relate a rather peculiar case which occurred in my practice two years ago. I was called, one morning, to a patient who was suffering from severe pains, I had never treated this gentleman before except perhaps for a slight cold or ordinary trouble, and I made an examination; found him lying on his back, limbs drawn up, - very tender at McBurney's point. Of course I diagnosed it appendicitis, and gave him several remedies with no result. He got to showing septic conditions so I suggested an operation to which he very strenuously objected. However, his wife insisted that he should submit, and I called in a surgeon from Philadelphia, who had not seen the case before. He came out, and made an incision for an operation for appendicitis. After getting through the skin a lot of pus oozed out, and a few seconds afterwards, small gall stones made their appearance. We then found he had ruptured the gall bladder. The incision was carried upward and the gall bladder exposed and drained. That man made a good recovery. I learned, afterwards, that he had frequent attacks of what he called pain in the stomach and he said he had always used Harlem oil to remove it.
Dr. Roberts (H. A.): I want to bear out what Dr. Boger has said in regard to Lachesis. I know of cases that have gone on, - cases where there was great distention of the gall bladder - where temporary relief was obtained. I remember having a case of gall-stones in a boy of sixteen years of age, and I was called for the first time to see the patient during the attack. There was great distention of the gall bladder and pain. I was able to relieve the pain with Lachesis but it did not relieve the condition, and I advised an operation very strongly, but it was refused. The boy died within two or three days, afterwards from a ruptured gall bladder. I do believe that, as physicians, we must re-define the line of demarkation. As I said before, in my opening remarks, there must be a strong line of demarkation between pure surgery and therapeutics if you are going to save your patients in these critical conditions.
Another point was brought out in one of these discussions - and that is in regard to cancer. It is well to bear this in mind that the localization of cancer is apt to take place at the point of irritability and a packed gall bladder certainly gives irritation, and there is danger of this being followed by cancerous growth.
Dr. Becker (Henry): I would like to hear more from those who have had experience with the results from operation. Dr. Patch has given us several instances where operation on the gall bladder has had good results. I am skeptical with regard to operation for gall-stones. I have seen numerous cases with very bad results and I can remember no single case where a good result was obtained. My experience has been most satisfactory with medical but not with surgical treatment.
PAGE 212
In Toronto a very efficient Old School surgeon was operated on for gall-stones. He has never been well since. A big, six-foot, healthy, active man. I said "You know you don't get good results from operation in gall-stones," and he agreed with me. I said with Homoeopathy we cure this trouble and I said "Why didn't you see my brother, who is a friend of yours, before undergoing the operation?" He answered "If I had to do it over again I would."
Sinuses often do not heal up well with us, which you will probably say is due to bad surgery. It does not seem to be because this operation has good results in other abdominal sections, but the health seems to break down generally.
Dr. Krichbaum (Philip E.): Any sycosis back of it?
Dr. Dienst (George E.): It seems to me to be merely a matter of accurate diagnosis. All causes looking forward to the formation of stones in the gall bladder are curable before the stones are formed, and as long as Nature is able to throw off a substance the size of a gravel stone and the conditions express themselves in intelligible symptoms, it is a curable condition. But when a stone enters the bladder, when the accumulation in the bladder is of such magnitude that it cannot pass off, then it is time to act.
I cannot answer Dr. Becker because I have never had a case of gall-stones that had to be operated upon. All that I have ever seen have been in the primary stages, and if you can recognize, in the beginning, when the gall bladder is becoming affected, where it is setting up symptoms, then is the time to use your remedy; not always the same remedy, - various remedies will cure the condition. But I want to emphasize the point that is clear in my mind, but not in my expression, that there comes a time when Nature cannot respond to the remedy; then it must respond to the knife.
Dr. Roberts: In regard to Dr. Boger's inquiry, - my experience has been this. I have had several cases of gall-stones. Possibly down his way they do not have gall-stone cases, but in Connecticut we do have them a plenty, and I have had quite a good many of them operated on. I have only failed in one to get good results and that was where the patient was in a very critical condition to begin with, and in order to get her off the table alive, she was so far exhausted that we did not remove the gall bladder. We did remove the stones, - fourteen of them, packed in tightly, and made to order; large ones. Afterwards, a second operation was performed because of distress in the region of the gall bladder and instead of stones, we found a thick viscid fluid that has been spoken of as a viscid substance in the gall bladder, and the gall bladder then was removed. She has since recovered, and is fortunately in good health. That is the only one, in my experience, where the operation has not given satisfactory results. Now, do not understand me to say that every case of gall-stones is for the knife. In those cases where the gall-stones are sufficiently large to fail in passing, and you get an impacted condition, I cannot see anything but to remove them by mechanical means if you are going to get health for the patient.
Dr. Boger: I have seen both poor and good results. Some of the worst cases I have seen after operation resulting in suffering afterwards and general poor health, and it was very evident they were not cured. Perhaps Dr. Krichbaum is right - there was a sycosis back of it, but I have also known good results from surgical work.
Dr. Dienst: What per cent did you say?
Dr. Boger: At least a fourth.
Dr. Roberts: In regard to the fact that you found so many stones in the autopsies is along the same line as in the Johns Hopkins University Hospital where the autopsies showed that ninety-five per cent of all the patients had at some time in their life had tuberculosis, many of them without having known it. What is a manifest irritation to one constitution does not effect or phase at all another constitution in a similar condition, and that is the reason why you get a source of irritation from these conditions in the gall bladder in one patient and not in another under similar conditions; because there is some sycosis back of it that is disturbing.
I might ask Dr. Krichbaum to characterize that condition of sycosis in relation to gall-stones but instead I will ask Dr. Rabe to close the discussion.
Officers
Henry Becker, Toronto, Can. . . . . . . . . . President
Henry L. Houghton, Boston, Mass. . . . . . . . . . Vice-President
William R. Powell, Philadelphia, Pa. . . . . . . . . . Treasurer
Frank W. Patch, Framingham, Mass. . . . . . . . . . Secretary
Harry B. Baker, Richmond, Va. . . . . . . . . . Cor. Secretary
Board of Censors.
C. M. Boger, Chairman, Parkersburg, W. Va.
Guy B. Stearns, New York, N. Y.
John B. Campbell, Brooklyn, N. Y.
S. L. Guild-Leggett, Syracuse, N. Y.
Erastus E. Case, Hartford, Conn.
Board of Publication.
Edwin A. Taylor, Chicago, Ill.
John Hutchinson, New York, N. Y.
Grace T. Stevens, Northampton, Mass.
Frank W. Patch, ex officio, Framingham, Mass.
Proceedings of the thirty-seventh annual session of the International Hahnemannian Association
HELD AT THE ALDINE, PHILADELPHIA, PA. JUNE 21, 22, 23, 24, 1916.
