INTESTINAL COLIC. — III intestinal colic the seat of pain and the character of the latter differ from those of biliary colic. Chills and fever accompany bil iary more frequently than gastric or in testinal colic.
AcuTE APPENDICITIS. — The differ entiation of acute appendicitis is some times very difficult, especially in cases in which adhesions to the under-surface of the liver follow an attack. Differ ence in the seat of pain in first attack is nearly- always marked.
In biliary colic the pain often radiates upward to the shoulder, while in ap pendicitis it is experienced in the region of the umbilicus.
In the writer's experience, it is of the greatest importance to note down ac curately the history of the case and to observe whether the symptoms are he patic, renal, or intestinal. A careful examination into the clinical history is of almost as much importance as are the physical signs.
The presence of gall-stones in the fTces is the crucial test in the diagnosis. These may escape observation unless (Treat care is taken in the examination. The stools should be made as fluid as possible by- the addition of water and passed through a fine sieve. The prin cipal points in the diagnosis of chronic cholelithiasis are the attacks of pain more or less severe in the hepatic region, tenderness of the liver, the presence of a tumor resulting from perihepatic in flammation or abscess, exacerbations of fever with or without local pain; jaun dice, usually intermittent or remittent; not often persistent and increasing.
The differentiation between a dis tended gall-bladder and a displaced right kidney is often difficult. It is not infrequently impossible to make a distinction by noting the shape and size of the tumor; occasionally all the meth ods generally laid down, such as the movements of the gall-bladder by respi ration, the limitation of its movements, and the relative situation of the colon, are all of little use. Sometimes by care ful palpation the kidney and gall-bladder can be separated and a positive diagnosis made.
Number of eases in which g,all-stone crepitus was made out and proved to be of great diagnostic value. The erepitits
may be obtained by palpating with the finger-tips dipped gently, but deeply, in the abdominal wall just below the fun dus of the gall-bladder and then drawn upward over the organ as though mak ing an attempt to roll the fundus up ward and forward. Deep inspiration is helpful and the tactile sense of the pal pating fingers may be increased by 'wells ing on their dorsal surfaces with the dis engaged hand. Auscultation is some times successful when palpation fails, and a combination of the two has led to the detection of a friction-sound. In ratempting the latter mode of examina tion the stethoscope should be placed just below the costal arch, in order to allow space for the palpating right hand over the fundus of the gall-bladder. J.
Anders (Inter. Med. Mag., Dec., '99).
Palpation for the lower margin of the liver should be conducted in the follow ing manner: The physician, seated to the right of the recumbent patient, places the left hand flatly on the abdo men in the hepatic region, and endeavors by means of gentle pressure with the tips of the fingers to ascertain the situ ation of the lower edge of the liver. When he thinks he is near to the liver';; edge, the fingers of the right hand are placed obliquely upon the left (the right index finger corresponding to the left little finger, and -rice versa) in such a manner that the tips of the fingers of the right hand slightly overhang those of the left. Firm pressure is exercised with the right hand upon the subjacent passive left.
If by means of this "octodigital" pal pation the liver-edge cannot be felt in the right mammary line, there is no hypertrophy of the organ.
If the liver is enlarged—especially if its volume presents manifest fluctuations from time to time, augmenting during, the attacks of pain and diminishing in the intervals—and in addition abdominal tenderness is found to be present, a diag nosis of hepatic colic may be made. Pol latschek (La Scinaine Mild., Apr., '99).