1. The diagnostic value of the point of maximum tenderness on pressure, which is over the gall-bladder at or near the costal margin of the ninth rib. This point in disease of the gall-tracts corresponds in importance with McBurney's point in disease of the appendix.

2. The diagnostic value of the presence of bile in the urine excreted during or immediately after a very brief obstruction of the common duct.

3. Disease of the gall-tracts is of very common occurrence, and is liable to be mistaken for other troubles which it closely imitates.

J. H. Musser calls attention to one or two facts in variance with the commonly-accepted notion of the clinical concomitants of gall-stones, and says:"1. Gall-stones may Occur at an earlier age than we usually suppose. A man, aged 23, was operated on by Dr. Martin, for me, and 200 calculi removed. He had hepatic colic from his fifteenth year.

"2. Pain may be the only symptom. It may be in various localities. In a case I saw with Dr. Sprenkel (operated on by him) the pain was seated at the xiphoid cartilage.

"3. Jaundice may never be present. "4. Rigors and fever may be the most pronounced symptoms, pain being complained of very slightly.

"5. Of great importance, as an indication of their presence, is the occurrence of persistent localized tenderness in the gall-bladder region, often elicited only on deep palpation when the patient takes a full breath. Gall-stone crepitus may be felt.

"As with hepatic disorders, so with surgical affections of the biliary passages; they must be excluded from af

they simulate. Of these, subdiaphragmatic abscess, appendicitis, intestinal obstruction, and acute pancreatitis are the most common.

"Gall-stones, on the other hand, may be simulated by hysteria, acute flatulent dyspepsia, appendicular colic, renal colic, liver colic, pain in the intercostal nerves from osteitis of the spine, malignant disease of the liver, and pyloric obstruction.

"The surgeon must be chary concerning the diagnosis of cholecystitis and its operative interference in all cases in which the liver is enlarged, even though jaundice, pain, and symptoms of infection may be present. Such enlargement is likely to be due to diffused suppurative cholangitis and multiple small abscesses, or to subdiaphragmatic abscess, or to cancer of the liver, or, in rare instances, to forms of cirrhosis, or to syphilis of the organ."

A case of multiple gall-stones in the gall-bladder, simulating cancer, operated upon by Abbe.

was

The patient

was a woman, 60 years old, who had never had gall-stone colic, but who for three months past had suffered from abdominal pain and loss of weight: about two and one-half pounds weekly. She had no fever, her urine contained bile, and the stools were clay-colored. Jaundice came on slowly during the last ten days. There was a tumor on the right side of the abdomen, which had slowly grown to the size of a cocoa-nut, and on account of its mobility her physician regarded it as a movable kidney. She had the exhaustion of profound cholæmia. Personal examination

'Med. Record, Oct. 20, 1900.

'Phila. Med. Jour., Oct. 6, 1900. 'Med. Record, Dec. 8, 1900.

showed a cocoa-nut-shaped tumor, which was so movable in the abdomen that it bobbed about and could be moved down to the groin and nearly across the median line. When at rest it was below the right ribs. The mass was brought over to the median line, and under cocaine anæsthesia, aided by a few whiffs of chloroform, it was evacuated through a median incision, a pint of white glairy fluid and 343 gall-stones being removed. The bile immediately began to flow freely through a tube in the distended gall-bladder, and the patient made a perfect and very rapid recovery.

M. H. Richardson states that, in the diagnosis between a gall-stone impaction and cancer of the pancreas, ascites with jaundice favors cancer. Gradual loss of weight and the absence of pain are strong confirmatory signs.

Absence of pain is significant of simple pressure upon the common duct, and favors a new growth in the pancreas. Yet the absence of pain is not incompatible with the presence of a long-impacted stone if there was a distinct attack of sudden pain in the beginning. The element of suddenness in the appearance of the jaundice, too, is important as indicating a stone rather than a neoplasm in the pancreas.

Changes in the stools peculiar to diseases of the pancreas should be noted, for their presence may definitely establish the diagnosis.

and biliary ducts. It is more probable that gall-stones will follow as the result of low, chronic inflammatory condition than after an acute or virulent type. The precipitation of the essential elements necessary for the formation of a nucleus requires a considerable length of time for its consummation, and such progress is hindered or more frequently absolutely destroyed, when a very acute or virulent variety of inflammation attacks the gall-bladder .or biliary passages.

During February, March, April, and May of the past year A. J. Ochsner' operated upon 18 patients suffering from gall-stones, and of these 6, or onethird of the entire number, suffered at the same time from appendicitis. In each one the extensive adhesions, or the cicatricial contractions, showed that the patient must have suffered from a violent, acute attack of appendicitis at some time, and in each case the appendix contained septic material in the form of fæcal concretions or pus. It seems clear, then, that during the acute attack an infection of the gall-bladder with the colon bacillus could have been easily accomplished, and this also would have been possible during the longcontinued chronic appendicitis following.

Cushing and others have pointed out the fact that a considerable proportion of all patients suffering from gall-stones have previously had typhoid fever. Mignot and others have shown experimentally that the colon bacillus is capable of causing the formation of the gall-stones. Gilbert and Fournier seem

'Phila. Med. Jour., Oct. 6, 1900. Post-graduate, Nov., 1900. 'Phila. Med. Jour., Oct. 6, 1900.