tion; the pulse was 120, temperature 103°. Palpation revealed a tumor of the size of a goose's egg in the region of the gall bladder, which was very painful to the touch. Dr. Fischer had diagnosticated empyema of the gall bladder, caused by cholelithiasis, and had insisted upon an immediate operation.

Laparotomy, performed at St. Mark's Hospital, revealed adhesion of the gall bladder to the omentum. Although they were separated with extraordinary care, the gall bladder ruptured under my fingers, about a tablespoonful of thin, gray, malodorous pus escaping. Notwithstanding the gall bladder had been surrounded with sterile-gauze compresses, I was unable at the time to prevent some of the pus coming in contact with the omentum. The adjoining tissues were irrigated liberally with a hot salt solution, and iodoform powder was rubbed into the adjacent surfaces. No calculus was found. Cholecystotomy and partial iodoform-gauze drainage; removal of the gauze drain after twenty-four hours; uninterrupted recovery, and closure of the fistula three weeks after the operation. It seems to me that in this unusual case a gallstone had obstructed the common duct, had caused inflammation, infection, etc., and still passed into the duodenum, the condition of the gall bladder not being influenced by it.

A less fortunate case of a similar kind is the following:

CASE V.-A. R., 36 years of age, having suffered from digestive disturbances and colicky pains in the epigastric region, was treated by the various physicians he employed, mostly for dyspepsia, for several years. Four days ago he was taken suddenly with symptoms of peritonitis. Dr. Waechter, who was called in then, advised an immediate operation, to which the relatives of the patient objected. Only when the condition became very desperate, the patient was sent to St. Mark's Hos pital, where, on performing laparotomy, I found general peritonitis and a large abscess, the walls of which were formed by adhesions around the omentum, the transverse colon, and the perforated gall bladder. In the midst of the thin, malodorous pus a hundred and ten gallstones, all of the average size of a pea, were found. Death two days later from sepsis.

CASE VI.-M. C., 26 years old, the mother of four healthy children, has suffered for four years from occasional pain in the hypochondrium as well as in the epigastrium, which were regarded as "stomach cramps." During the last fifteen months she has had four attacks of a very severe character. She yelled and threw herself about in such a manner that hysteria was diagnosticated. The treatment was in accordance, although she insisted that her pain was located in the region of the gall bladder. The last attack being unusually severe and her actions becoming like those of a maniac, a neurologist was called in.

On his examining the patient thoroughly, besides hyperesthesia nothing abnormal could be detected. But on watching the fæces, the presence of a gallstone was discovered. Consequently medical treatment for cholelithiasis was iustituted. Despite the administration of large doses of morphine it was impossible to check the pain, so that" as a last resort' surgical interference was proposed. When I had an opportunity to see the patient for the first time slight icterus had just developed. The pulse and the temperature were normal. Vomiting and nausea were present. The abdomen was soft. At the classical spot a slight resistance but no tumor could be felt. There was hardly any pain to the touch. The urine showed traces of biliary coloring matter. The patient was greatly exhausted, and this probably had caused the subsidence of her "hysterical symptoms.' On the following day cholecystostomy was performed at St. Mark's Hospital. After the walls of the slightly thickened gall bladder were divided, two hundred and eighty-six gallstones, varying in size from that of the head of a pin, were removed. No bile was present. Thinking that I had evacuated the gall bladder thoroughly, as, on introducing my finger into it, I could not find anything abnormal, I palpated the common duct from the outside and discovered a hard mass in the common duct. By pressing and pushing I succeeded in dislodging a soft gallstone of the size of a walnut into the gall bladder, from which I was able to extract it after many unsuccessful efforts. This large stone had apparently occluded the common duct only lately, thus explaining the incipient icterus. No reaction followed. Normal bile was discharged in twenty hours after the operation.

The various conditions described above may be confounded with all the different diseases of the liver, which may also produce jaundice, particularly with processes like suppurating gummata or echinococcus, liver abscess in the tropics, and pyæmia dependent upon appendicitis or hæmorrhoids. Furthermore might be considered perforating ulcer of the stomach, subphrenic abscess, inflammatory processes, and neoplasm in the pancreas and duodenum, etc.

It must also be borne in mind that a patient may suffer from any of these conditions described and at the same time his gall bladder may contain stones.

It had been expected that under anesthesia the distinction could be made easier. But, unfortunately, the respiratory motions prevent exact palpation. Percussion is also quite uncertain, as the lower margin of the liver is generally so thin that tympanitic sounds are more or less audible through it.

It had been expected that the Röntgen rays would give some elucidation of these obscure points, but, unfortunately, gall. stones are permeable to the rays, so that only an indistinct shade is obtained. Neusser, Goodspeed, and Cattell (Medical News, February 15, 1896) state that they have been able to diagnosticate the presence of gallstones by the rays. I have tried various experiments with the rays, but without being able to demonstrate the presence of gallstones, in two cases where the symptoms of their existence were well developed. We may hope, however, that future improvements of the Crooke's tubes will enable us to obtain more distinct skiagraphs.

So we see that the main diagnostic point is the pain. And even here it has to be considered that often the pain is not localized at the classical spot below the hypochondrium, but is very frequently confined to the epigastric and to the cardiac region. Even the right iliac fossa is painful sometimes, so that appendicitis is naturally looked for. It should also be borne in mind that the pain is frequently not of a colicky character.

Sometimes, when jaundice is absent, minute examination of the urine shows distinct bile-pigment reaction. In all of my non-icteric cases the urine was examined carefully, but gave no information. Fever is also a very unreliable symptom. As a rule there is no rise of temperature during the typical colics, while at least in the beginning of the process-there is a decided elevation when ulceration and infection have taken place. Sometimes when the stones pass the common duct, a temperature of 105° has been observed shortly after, the thermometer registering 99°; and, vice versa, empyema of the gall bladder and ulceration are observed under normal temperatures.

This shows how difficult it is, in many instances, to diagnosticate cholelithiasis. But even when the diagnosis is made early, what then? The general therapeutic custom is to send patients who can afford it to Carlsbad, and to treat others with Carlsbad water or salt, with olive oil, with glycerin, with salicylate of sodium, etc. There can be no doubt that the alkaline-saline hot springs of Carlsbad induce peristalsis and stir up the circulation in the abdominal organs, particularly in the liver, where so often cholangeitis and cholecystitis are present as a consequence of cholelithiasis. Such inflammatory processes are often cured, at least the stones become quiescent, so to speak, and the chole

lithiasis becomes, as Riedel says, "latent." This explains fully why such a great number of patients who have suffered intensely from "" gallstone colics" feel well after using the water for a few days only. Copious defecation is undoubtedly a great factor in this relief. Nothing illustrates this better than the fact that patients who, after long suffering, alleviated only by morphine, have determined to submit to an operation, change their minds suddenly as soon as the bowels are thoroughly evacuated. Their relief is then so great that they cannot be persuaded that the operation is still indicated.

It is interesting to hear that Kocher, one of the most enthusiastic pioneers in the surgery of the gall bladder, said, when he suffered from cholelithiasis himself: "It is most surprising how a trifle of this water, taken during three weeks, effects as much as the stone-removing knife." Kocher suffered the most intense pains before going to Carlsbad, and since then he has never experienced any pain to speak of.

No stones, however, were passed, and so it must appear probable that we are confronted with a case of cholelithiasis which became latent after the inflammatory process had subsided. So it seems that the hygienic, medicinal, and balneological therapy cures the consequences of the stone-that is, the inflammation and the pain resulting from it. But a real cure of cholelithiasis is but seldom effected, the stones remaining where they were before. A perfect restoration to health would imply not only the subsidence of the symptoms described, but the entire removal of the stone or stones. It would furthermore mean the restoration of the bile-producing elements to a normal state, with no tendency to the formation of stones; and last, but not least, it would imply that the biliary system was entirely pervious. So we can readily see that after the diagnosis of cholelithiasis is made our strategy is by no means always determined. A series of questions still have to be answered; such as, in the first place, whether the pains are due to the passing of stones through the common duct or to cholecystitis. It seems that the latter is much more frequently responsible for the pains than is generally supposed. Furthermore, it must be considered that the pain persists even after all the stones have passed, the adhesions around the gall bladder being the only cause of them.

Only surgery can answer these questions properly; as the autopsy in vivo teaches the operating surgeon how often, before opening the abdominal cavity, he errs in his assumptions. From the experience gained by these errors the surgeon will learn how best to avoid them in the future.

The surgeon also learns by ocular demonstration that cholelithiasis is by no means the innocent disease which it is regarded as a rule. It may be latent for years, and may kill suddenly in the midst of apparent health. There may be several so-called colics followed by perfect euphoria; and, just as well, there may be a fatal result after the second attack. So the prognosis of cholelithiasis is always questionable. Innocent as it may be in the latent stage, when the stone is at rest and the bile passes freely, it will become terrifying as soon as the duct becomes occluded and infection takes place. It is thus a very misleading feature of cholelithiasis that the symptoms so often do not appear to be very serious, while intra-abdominally the gravest lesions are going on. And if the stone really passes the cystic duct, but not the papilla, the character of the reaction will be selfevident. While in such cases the stone, as already said, is discharged once in a while per vias naturales, in by far the greater majority of such cases the patients succumb, the true cause of death but seldom being elicited. The analogy with the various forms of appendicitis is obvious. In fact, if a patient gets a second attack of appendicitis he is almost sure to get a third and fourth one, and it will be only a matter of time when he will succumb to one of these attacks. The difficulty in deciding upon the proper treatment is also nearly the same. With slight modifications the same indications may be upheld for the treatment of cholelithiasis. In Case III the patient submitted to the operation at a comparatively early stage, and still it was too late, the pathological changes having become enormous and quite out of proportion to the clinical aspect of the case. There is not the slightest doubt in my mind that this patient would have been

saved had the operation been performed early enough. But could a diagnosis be made at such an early stage? And if so, would it be possible to persuade the patient to submit to cholecystotomy at a period when as yet he was suffering but very little?