If after a careful examination into the history and present coiadition, especially an analysis of the urine, the symptoms and signs are found to be hepatic rather than renal, the tumor will probably be a distended gall-bladder. As before stated, a displaced kidney attached to the under-surface of the liver may cause jaundice by drawing the common bile duct out of place.
When anatomical conditions are fa vorable, disease of the pancreas may occur as a complication of cholelithiasis when a calculus passes along the com mon bile-duct. The lodgment of a stone near the orifice of the bile-duct where it may at the same time compress and occlude the duct of Wirsung, is not un commonly a cause of pancreatic lesions and disseminated fat-necrosis. Should a calculus become impacted in this posi tion, one of several conditions may re 1. An individual, usually in fairly good health, with perhaps a history ot previons gall-stone colic, is suddenly attacked with pain in the epigastric region, accompanied by vomiting and followed by collapse. Death follows usually within forty-eight hours, and at autopsy gall-stones a.re found in the bile-passages, while that one which caused the fatal attack may be still lodged in the common duet near its ori fice. The pancreas is enlarged, infil trated with blood, and hremorrhage may have occurred into the surrounding tis sue. Foci of fat-neerosis are usually present.
2. A fatal termination may not follow rapidly the symptoms mentioned. Pain in the epigastrium persists, jaundice may be present; and a tumor-mass above the umbilicus may indicate a, probable lesion of the pancreas. At the end of one or more weeks or months death occurs, often with symptoms in dicating the presence of suppurative in flammation, presumably in the neighbor hood of the gland. At autopsy the di agnosis of cholelithiasis is confirmed by the presence of gall-stones in the gall bladder or in the hile-ducts, and occa sionally the offending calculus is still lodged near the junction of the com mon bile-duct and the duct of Wirsung. The pancreas is dry, black, and necrotic, and evidence of previous hfcmorrhage niay be present. Secondary infection has occurred, and the pancreas lies in an abscess-cavity formed by the bursa omentalis. In the wall, and often
widely disseminated in the abdominal fat, are foci of necrosis. Since the in dividual has survived. the primary le sion, opportunity has been given for the development of secondary changes in the injured pancreas and neighboring fa t.
3. In certain instances long-continued or repeated obstruction of the pancre atic ducts by gall-stones does not cause the acute lesions described, but pro duces chronic inflammatory changes. E. L. Opie (Amer. Jour. Med. Sci., Jan., 1901).
A distended gall-bladder may require to be differentiated froin pyloric and in testinal carcinoma, kecal impaction in the colon, tumor of the liver and of the right kidney; also from a tongue-like projection of the liver, which is occa sionally found.
Attention called to eases of acute cholecy.stitis of ttudden onset in patients of apparently perfect health, in whieli there is no history of gall-stones. and which do not depend on typhoid fever, pneumonia. or other infective processes. Of 59 cases of eholecystitis personally operated on only 10 began withont known pre-existing' di.sease. Three of the 10 eases were diagnosed as actite appen dieitis with such certainty that the in cision -MIS made over the appendix. In 2 the symptoms were those of acute in testinal obstruction.
Again, the disease may be mistaken for the sudden closure of an organic stric ture, for an inflammatory process in a diseased kidney, an acute peritonitis, an acute panereatitis.R11 extravasation from the stomaeh, a malignant abdominal tumor, or a tumor with a twisted pediele.
If the symptoms point to the gall bladder rather than to the appendix the incitdon should be made over the former and ricr rcr.vt. When there is great doubt as to which is affected, the cut may lie made behind the caecum, high up and enlarged in whichever direction is required. AVhen there is no localized pain or tumor or history pointing to a definite lesion, the incision tdiould be in the middle line.
Seven of the 10 eases recovered. Rich ardson (Amer. Jour. AIed. Sciences,June, '98).