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THE structures located in the upper right quadrant of the abdomen are in such intimate relation with each other that in making a diagnosis, confusion with pathological changes which might have taken place in any of these various organs must be carefully considered. The biliary system is of all these structures the richest in possibilities, and of the various diseases attacking this system, gall-stone is by far the most frequent. In establishing a diagnosis of gall-stones the previous history of the patient is of much importance in enabling one to reach correct conclusions. Even though the history be ever so full and complete I may say it is possible to err in making an exact diagnosis.

The classical symptoms of gall-stones are usually described as intense pain of a colicy character radiating to the stomach or perhaps over the entire abdomen, or the right shoulder blade; nausea and vomiting; jaundice and passage of gall stone in the bowel movement. Many of the cardinal symptoms, however, may be wanting in these cases, and should

• Read before Tri-State Med. Assn. (Miss. Ark. & Tenn.) Memphis, Jan. 19, 1904 Vol. 24-9 113

we entirely depend upon their presence for a positive diagnosis many cases would remain in obscurity. Jaundice is no longer considered of importance in the diagnosis of gall-stones. The signs which are of much value in establishing a diagnosis are disturbances of digestion, nausea after meals and a sense of fullness, also perhaps a dragging sensation in the gall-bladder region. Pain is usually felt in the stomach or its vicinity, or over the fundus of the gall-bladder, radiating to the right shoulder; on palpation a point of tenderness at the border of the ribs may be clearly elicited. Murphy has demonstrated that this tenderness is best obtained with the patient in the supine posture, then with the fingers hooked up under the border of the ribs the patient is directed to take a deep inspiration. This act causes the diaphragm to depress the liver and thereby brings the gall-bladder against the tips of the fingers, causing pain if gall-stones be present. A tumor is rarely felt unless the disease is of very long standing and the tissues matted together by inflammatory exudate. Under such conditions a mass might be detected, providing we were able to satisfactorily use palpation; usually there is so much pain we are compelled to desist in this method of examination. The liver may or may not be enlarged. When no obstruction to the outflow of bile exists the sclera and skin have a slightly muddy appearance, which is easily discernible, but is not by any means deep enough in color to be termed jaundice. Should the symptoms enumerated be also accompanied by the classical signs, colic, jaundice and passage of stone, then the diagnosis would be more clearly confirmed. There are conditions which may cause colic of the gall-bladder other than gall-stones, as inflammatory swelling of the mucous membrane obstructing the flow of bile, or when the gall-bladder is drawn downward by adhesion causing a kinking of the cystic or common duct.

The diagnosis of non-calculous cholecystitis is of importance, for this affection is still considered by some to belong to the internist, while calculous cholecystitis is purely surgical. Here again the previous history is of much importance; cholecystitis occurring where no history of previous biliary colic is obtained, or arising during or after infectious diseases, as typhoid fever, is in favor of simple cholecystitis un

complicated by gall-stones. Cholecystitis is a much more common affection than was formerly thought to exist. Musser states that it not infrequently occurs after typhoid fever, and it seems very probable in the present state of our knowledge that the so-called relapses of typhoid fever are not infrequently nothing more than cholecystitis, as evinced by the septic temperature, the fever approaching the normal in the morning and rising in the evening. Usually there is some pain and tenderness over the gall-bladder, but these symptoms may be practically absent. When cholecystitis is severe we have the symptoms of local peritonitis over the gall-bladder. Should the inflammation assume the gangrenous type the symptoms may abate and the general condition seem better, but soon shock appears and peritonitis of virulent type is evident. The pulse becomes weak and thready and death frequently results. Musser again states that "catarrhal jaundice is a term which will have to be eliminated to a great extent from medical literature. This form of jaundice commonly follows some infection of the biliary passages."

Independent of gall-stones there may be jaundice due to inflammation of the mucous membrane, which by its swollen condition interferes with the flow of bile. Jaundice is intense when a stone passes into the duct and produces an acute obstruction. Associated with jaundice in this condition there is severe colic, nausea and vomiting and fever. Should the inflammation subside and the stone pass into the duodenum all symptoms will subside. Should this happy termination fail to occur, colongitic symptoms, with fever and rapid pulse manifest themselves. The so-called lobe of Riedel which overlies the gallbladder may at times present pathological conditions which so closely simulate gall-bladder disease that it may be impossible to make a correct diagnosis. Syphilis of the liver manifests itself in this lobe, and this condition has twice led me astray. Both cases were females and presented histories of acute attacks of pain in the upper right quadrant and under the margin of the ribs, radiating to the right shoulder and stomach. On palpation, there was hypersensitiveness over the gall-bladder. The first case presented an indistinct fullness, but no tumor could be made out on account of the pain. At the time of

operation many adhesions were encountered. These were separated and a suppurating gumma in the lobe of Riedel was found. Excision of the mass was done, the wound in the liver sutured, and a strip of gauze placed over it for drainage. The abdominal wound was closed to the gauze. Recovery promptly ensued, and by prolonged use of potassium iodide there was complete restoration to health. This case had been seen by a number of prominent physicians, and all concurred in the diagnosis of gall-stones.

The second case presented only a few adhesions. The gumma was found to occupy the lobe of Riedel and extended to the gall-bladder, but did not include it. No suppuration in the gumma having taken place, the wound was at once closed without drainage. The after treatment consisted of large doses of potassium iodide. Since operation health has been completely restored. In one case I had an opportunity to note the effects of the catarrhal process of measles on the biliary mucous membrane. I had operated on a young lady for gall-stones, removing several hundred from the gall-bladder and two from the cystic duct. For two weeks following the operation her progress was uneventful. At this time several cases of measles developed in the hospital, and among the number she was one. The bile had almost ceased to flow through the wound, and it seemed as though in a few days more the fistula would close. After the onset of the disease the bile began to pour out of the wound in vast quantities, saturating the dressings every few hours. This continued through the height of the disease, declining as the measles grew better, and finally ceasing altogether.

The close analogy in the symptomatology and pathology of the appendix and gall-bladder should be borne in mind. It is the present day tendency to consider cholecystitis and appendicitis in the same surgical light. Many operators hold that cases of cholecystitis, like appendicitis, should be operated on at once. Should the case be seen late and progressive amelioration of symptoms taking place postpone operation till the interval. Appendicitis may simulate gall-bladder disease or vice versa. The appendix may be situated high up, or the gall-bladder low down, and thus produce a condition which is

either difficult or impossible to properly diagnosticate. Many such errors are recorded in medical literature. I assisted in an operation where the symptoms pointed to appendicitis, but operation revealed a gangrenous cholecystitis. The patient was not seen till late in the disease, and at the time of operation there was little hope of recovery. An overwhelming amount of toxin had been thrown out in his system, and death came in a few hours after removal from the table.

It has been said that the treatment of gall-bladder disease resolves itself into medico-surgical and surgical measures. In certain cases, under proper medical management, the symptoms will at least temporarily subside, but the internist, especially in cholecystitis, should have the surgeon close at hand in order to meet any emergencies which might arise. It is questionable whether or not cholecystitis and cholelithiasis are ever permanently cured by internal medication. The inflammatory process may subside and recovery seem assured, but it may be relighted at any time. Quite a large number of drugs have been employed in the treatment of cholelithiasis, all of them, with the exception of opium and the Carlsbad treatment, may be discarded as having no place in this class. of cases. Morphin allays the pain and Carlsbad treatment allays the inflammation. Its cholagogue action, together with rest and diet, do much toward bringing about a quiescent state in the gall-bladder. Ochsner has formulated a treatment which seems to have given him good results. It consists in washing out the stomach, thus putting that organ at rest. He claims there is a synchronous contractility of the stomach and gallbladder, and by putting the stomach at rest pain ceases in the gall-bladder, a distinctly less amount of morphin is required. to relieve pain; in fact, in many cases the drug can be omitted after the flushing of the stomach. Heat is applied to the side and all nourishment given by the rectum in concentrated quantities and repeated once in four or six hours. When this treatment fails he advises operative measures. Cholecystitis is a serious disease, and at times deceptive in its course, for while there may be a tendency toward recovery, a progressive infection of the bile ducts may take place.

It is the present day tendency to operate as soon as the

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