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the surgeon. Only when, in spite of all hygienic, medicamentous, and balneological efforts, the patient becomes emaciated through the torments of the colics, when choloemia and pyæmia are imminent, an operation should be performed." And Riedel, the surgeon, answers: "On the contrary, surgery should interfere at the beginning, not at the end of the tragedy, and should as a prophylactic remove the stones from the gall bladder before they have a chance to do their pernicious work. But what can one do against the custom sanctified by centuries? On the strong walls of Carlsbad every attack will be repelled, without a care whether through the delaying policy of Carlsbad thousands will succumb or not."

Which of the two procedures is really the better? The answer is difficult. Let us try to decide, in the first instance, from a consideration of the diagnostic difficulties.

When jaundice is present in a patient and when stones are found in the fæces, even the layman may diagnosticate gallstones. But frequently all the symptoms described in the text-books are wanting. Among sixteen cases I had under my observation jaundice was developed but twice, and then only shortly before operation.

Gallstones may be present in the gall bladder for many years without causing any symptoms, the autopsy only discov ering them. Or a large stone may be in a normal bladder and the cystic duct be free. The stone being generally at rest, the cystic duct and the mucous membrane of the gall bladder being intact, there is no obstacle for the circulation of the bile, and a slight dragging only may be felt once in a while in the upper abdominal section. It may also be that under the same pathological conditions meteorisms and even vomiting may be caused. Or the whole annoyance may consist in slight temporary abdominal pain and the patient may not be able to digest all kinds of food, so that he naturally thinks he suffers from a "weak stomach." The patient may also be free from any trouble for many years, and only suffer from "stomach cramps," once in a while, and may die in old age from some other cause, the autopsy sometimes revealing the true nature of the stomach cramps. (Stomach cramps are with few exceptions nothing but gallstone colics.)

As the gall bladder in such cases is of normal size and of soft consistence, palpation will naturally fail to disclose anything. When adhesions should form the pain may be more frequent and a little more severe, but the local condition would remain just the same.

It is quite natural for such conditions to be confounded with ulcer of stomach, old catarrh of the stomach, or abdominal neu ralgia, not to speak of the rarer occurrence of adhesions caused by primary affections of stomach and intestines, displacements and version of the latter, syphilis of the liver, etc.

Or once in a while a stone may produce inflammatory process in the gall bladder, thereby causing marked swelling of the more or less hydropic organ, intense pain, meteorism, and vomiting. The presence of a pear-shaped tumor under the liver would then elucidate the case, although jaundice might be entirely absent.

The swelling of the gall bladder, however, may disappear, meteorism having been present for a short period, and the patient will feel greatly relieved. At the same time, although no stone is found in the passage, there is a strong inclination to believe that the stone was driven out of the bladder, the disappearance of the pear-shaped tumor, which could distinctly be palpated before, corroborating the wrong assumption. But the latter symptom is due only to the subsidence of the inflammation, the stone remaining in its habitat just as before. Such cases are often confounded with the so-called benign forms of appendicitis, and the mistake is not at all unpardonable, as the appendix is not infrequently found up as high as above the level of the umbilicus. The same thing may occur in the case of ileus, floating kidney, cholangeitis, caused by acute processes in syphilis of the liver, primary formation of calculi in the liver itself, ulcer or cancer of the pylorus, cancer of the ascending or transverse colon, and suppurative processes in the kidneys.

Inflammation, caused by irritation of the stone, may produce a swelling of the mucous membrane of the gall bladder which extends to the cystic duct and occludes the narrow canal. The mucous membrane of the gall bladder degenerates, the contents become decolorized, serum takes the place of the bile, and now we have to deal with the so-called hydrops. The size of

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the gall bladder may increase more and more, and at last the slight inflammatory process may extend over the neighboring organs under more or less pronounced symptoms.

Sometimes the patient has a hydropic gall bladder of the size of a mau's fist, without ever having noticed the slightest trouble from it, and indeed without knowing it at all. Sometimes there are more serious symptoms present, which may be entirely misinterpreted.

CASE I.-Mrs. L., forty years of age, mother of three healthy children, had suffered for nine months from occasional pain in the umbilical as well as in the right lumbar region. The physician who was first consulted diagnosticated lumbago and treated the case accordingly. When another colleague discovered a resistance in the umbilical region, and felt a slight bulging there when the patient coughed, umbilical hernia was thought of. When the patient at last suffered from frequent nausea, pain after meals, and became cachectic, Dr. John Weber, of this city, diagnosticated cancer of the pylorus. Considering the locality of the tumor and the absence of pain in the region of the gall bladder, I felt justified in indorsing this diagnosis. Jaundice was never present. Exploratory laparotomy in the linea alba revealed a long, pear-shaped gall bladder of the size

of a man's fist. The fundus of the tumor reached as far as an inch and a half below the umbilicus. Aspiration yielded serum. Adhesions had to be divided between the gall bladder and the omentum and transverse colon. The walls were so thick that they creaked under the knife. After their thorough division a stone the size of a goose egg was discovered obstructing the cys. tic duct. The gall bladder was sewed to the abdominal wall. There was no reaction. Normal bile was discharged copiously twenty hours after the operation. Three months later, after having been repeatedly treated with Paquelin's cautery, the fistula was obliterated. Final recovery was perfect.

But just the same, and for reasons unknown to us, the mucous membrane, after being inflamed first, may become eroded and ulcerated; at last infection takes place, and the contents of the bladder become purulent, so that we then have to deal with the so-called empyema of the gall bladder. Sometimes a slow perforative process under the formation of an adhesive inflammation takes place, and gallstones are discharged into the intestine.

Such cases are easily confounded with grave appendicitis. The patient becoming cured by the perforation, and the fæces not being examined for biliary calculi, it wrongly appears to be

another corroboration of the "benign character of appendicitis if treated properly.'

Or the inflammatory process is recognized before perforation had a chance to take place, the symptoms being those of peritonitis in general. Then, if the gall bladder be deeply situated, appendicitis may be assumed.

CASE II. Mrs. K., 57 years of age, of Jersey City, the mother of two healthy children, suffered for years from weak stomach, and once in a while from slight pains in the epigastric region. Lately she had had much pain in the umbilical region, with great emaciation, and vomiting once in a while. Icterus had never been present. Chills and intense pain in the right iliac fossa developing during the last three days, appendicitis was diagnosticated, and I was sent for to operate. In the midst of a tympanitic area between the spina anterior ossis ilii and the umbilicus, I found a resistance that gave the indistinct impression of a tumor of the size of a goose's egg. Percussion above this area showed marked dullness, which dropped off indeterminably upward. Vomiting had been frequent. The patient's general condition was very poor, the exhaustion great, pulse 120, temperature 102°. My diagnosis was intestinal carcinoma, causing acute adhesive inflammation and perhaps perforation. Immediate laparotomy was advised. It was performed in St. Mark's Hospital, with the assistance of Dr. Lowenstein, of Jersey City. When the abdomen was opened empyema of the much elongated gall bladder was found. The fundus of the gall bladder reached as far down as to an inch below the level of the anterior superior spine of the ilium. Ninety-six stones, faceted and of equal size, were removed, mostly by using an irrigator. The patient made a good recovery, the fistula closing eleven weeks after the operation. During four weeks after the operation altogether eleven stones passed through the abdominal opening. In this case I could manipulate and examine the gall bladder particularly well. I am absolutely sure that at the time of the operation no more gallstones were in the gall bladder.

Or a stone may be caught in the cystic duct, causing inflammation and subsequent ulceration. Virulent infection sets in rapidly, and while the fate of the patient is sealed, still clinical symptoms may be far from being vehement.

CASE III.-M. L., a man of 46 years of age, had always been well until, two days ago, when he was taken suddenly with chills, nausea, vomiting, constipation, and meteorism. was called by the attending physician to operate for intussusception. When I saw the patient first, at 4 P.M., he was still walk

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ing about in his room. No signs of collapse, temperature 100°, pulse 104, respiration normal. No icterus. The abdomen was so much distended that palpation revealed nothing definite. But the patient complaining of violent pain in the region of the gall bladder, I felt justified in diagnosticating cholecystitis from impacted gallstones. Four hours later I performed laparotomy at St. Mark's Hospital. I found diffuse peritonitis. The gall bladder, which could be approached only under great technical difficulties, was nearly totally gangrenous, filled with malodorous pus, aud containing five gallstones the size of a pea. In the cystic duct a stone of the size of a bean was impacted. Extirpation of the gall bladder; iodoform gauze packing; abdominal wound partially left open. Death on the following forenoon from sepsis. In this case the clinical symptoms were in no proportion to the local condition.

In all the various forms described so far no icterus had ever been present. It is evident that the diagnosis is much easier when icterus appears. In such cases the inflammation of the gall bladder may be very intense, icterus developing rapidly and disappearing again as soon as the inflammation subsides. Or a stone incarcerated in the common duct may cause inflammation with all its consequences. In such cases Nature may effect a cure, the stone passing Vater's papilla. Or, again, infection may take place with empyema of the gall bladder; yet once in a while the stone passes at last, the pus also discharging into the duodenum. But the rule certainly is that the patient succumbs before the efforts of Nature are successful, while art would have easily saved the life.

CASE IV.-Mrs. P. D., 31 years of age, mother of three healthy children, had repeatedly suffered from slight digestive disturbances and colicky pains in the region of the gall bladder for the last three years. Four months ago she became feverish, lost appetite and flesh, vomited once in a while, and also had diarrhoea. Then the diagnosis of typhoid fever was made. Three weeks after the onset of the feverish condition the patient improved again, was free from pain for four weeks, until three days ago she was taken again with chills, vomiting, and pain in the right hypochondrium. During the last twenty-four hours development of icterus; at the same time pains of labor of the pregnant patient setting in. A child of five months was born twenty-four hours after the onset of the icterus. (The child lived thirty hours in an incubator.) When I first saw the patient, a few hours after delivery, in consultation with Dr. Louis Fischer and Dr. H. M. Groehl, there was great exhaus

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