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palpable and tender. There was no jaundice. Upon opening the abdomen the gall bladder was found to be the size of a large lemon, with walls a third of an inch thick, containing four large gall stones and some tarry fluid. The fundus of the gall bladder communicated with a small abscess cavity the size of a walnut in the substance of the liver. As the cystic duct was not patent, it was ligated and a drain sutured to the stump. The gall bladder and abscess cavity were dug out of the substance of the liver, and several sutures taken to prevent hemorrhage. No suppuration occurred, and all drainage was removed on the fifth day. Recovery uneventful.

Case 6.-A. S. Patient had been suffering from severe gastric disturbances for six months, with pain, constant vomiting and symptoms resembling ulcer of the stomach. She had been confined to the bed for eight weeks, and was rapidly emaciating from fever and incessant vomiting. There was slight jaundice. The gall bladder was palpable and very tender.

Upon opening the abdomen a thickened gall bladder was found containing several stones, and one stone was incarcerated in the cystic duct. The gall bladder was extirpated, and a drain sutured to the stump. Recovery uneventful.

Case 7.-M. M. The patient had never thoroughly recovered from an attack of typhoid fever contracted six months previously. When first seen she had been in bed. with vomiting and pain in the right side, referred to the shoulder, and tenderness over the eleventh rib. The fever was remittent in character, with rapid rises and falls, and resembled malarial fever in many respects. The gall bladder was palpable and very tender. Upon opening, the gall bladder was found thickened, adherent to the colon and omentum, and covered with lymph. It contained sev

eral stones and some bile-stained fluid. One stone was impacted in the cystic duct, but did not completely block it. The cystic duct was cut across and drain inserted, and the gall bladder extirpated. Bile flowed from the drain three weeks, after which the serus healed and recovery uneventful.

Case 8.-M. C., age seventy-five years. Patient gave history of attacks of colic, with pain in the right side. When first seen he was in collapse, with abdomen distended and painful, with swelling and tenderness over McBurney's point. A diagnosis of ruptured appendicitis abscess was made, and incision made over appendix. Large quantities of bile-stained fluid evacuated. Appendix normal. The fluid had come down along the inside of the colon and pointed in the region of the appendix. Incision made through right rectus and a large gall bladder containing numerous stones of various sizes was removed. There were also several stones free in the abdominal cavity. Peritoneal cavity washed out and drained. Died in twelve hours.

To these eight operative cases are added two other cases illustrating different phases of the disease.

Case 9.-Patient had an attack of gallstones with jaundice, a month previously, and partly recovered. Attack returned ten days previously with great pain and fever, constantly getting worse. Was in collapse when first seen, with symptoms of peritonitis, and sent to the hospital, where she died, without operation, about twelve hours after admission. No autopsy allowed. Probably a case of rupture of gall bladder.

Case 10.-Patient had had several attacks of hepatic colic. When first seen had suffered a week from intense pain in the epigastrium and vomiting. Gall bladder enlarged and tender. Slightly jaundiced. Temperature

ranging about 100, pulse rapid. Was kept under observation five days and given medical treatment. Symptoms gradually grew worse, and patient became very weak. Was sent to the hospital for operation. The gall bladder could be seen distinctly pushing up the abdominal wall just before the anesthetic was begun. During the anesthetic she vomited a large quantity of green fluid. When she was brought into the operation room the tumor had disappeared. No operation was performed. Temperature and pain subsided and she went home the next day, and has had no trouble since.



In the diagnosis of gallstones we want to bear in mind that from fifty to eighty per cent. of the cases of gallstones have no jaundice, and that many have no rise in temperature. We should also remember that gallstones are more frequent in women than in men, three or four

to one.

It has been said that "indigestion is the most common symptom of gallstones." This very probably is true in chronic cases of cholelithiasis, and for this reason we often find it very hard to distinguish between cholelithiasis and many of the stomach troubles.

In periodic continuous flow of gastric juice, or gastrosuccorrhea continua chronica, we find pain, often severe, coming on four to five hours after eating, as in gallstone colic. But we find in gastrosuccorrhea continua large quantities of clear gastric juice with a high degree of free hydrochloric acid. If examined with tube we often find eighty to one hundred c. c of gastric juice and in four to six hours the same quantity may be vomited. The pain in gastrosuccorrhea continua is more on the left side and reflected to back on the left of spine, while the pain in gallstones is more to the right of the median line.

Gastric ulcer is often hard to distinguish from gallstone colic, but we find that the pain in ulcer is nearly always increased upon the ingestion of solid food, while

the pain from gall stones is not affected by taking food. The pain from gallstones is usually reflected to the back about the region between the ninth and eleventh ribs to the right of spine. Pain in ulcer may be reflected to the back, but on left side. There may be long intervals between the attacks of pain from gallstones, but the pain from ulcer is more continuous. We find in ulcer an excess of hydrochloric acid, while in cholelithiasis it is either normal or decreased.

If we have hematemesis or find blood in the stools the diagnosis of ulcer is of course easy. The pain from gallstones usually comes on while the stomach is empty, while the pain from ulcer comes on right after eating, or is made more intense by eating.

Duodenal ulcer, especially in the horizontal portion, often causes pain and tenderness in the region of the gall bladder, but the pain usually comes on two hours after food is taken. We are more apt to have a rise in temperature in gallstone colic than in ulcer of the duodenum. Ulcer of the duodenum is very rare in women—more frequent in men. Ulcer of the duodenum may give no symptoms till perforation. We may have hematemesis and melæna or may have melæna without hematemesis.

In cancer of the stomach the pain is more constant, but not so severe. We usually have a lack of hydrochloric acid in cancer of the stomach, and the presence of organic acids, especially lactic. It is possible for the hydrochloric acid to be in normal quantity or increased. If we can find the presence of a tumor or hematemesis and particles of tumor in wash that we may examine undc ̈ the microscope, then the diagnosis of cancer is more easily made. The pain from gallstones is often relieved Ly vomiting, and causing the stone to drop from the neck

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