There are three prominent symptoms of eholelithiasis in infancy and in child hood upon which the diagnosis is often based, namely: pain, vomiting, and con vulsions. Pain is usually referred to the epigastrium and is indicated in children by paroxysms of crying attended with severe vomiting. One of the most valu able diagnostic signs is persistence of the sensitiveness of the gall-bladder after cessation of the symptoms of the colic. The best means of eliciting this symptom is by placing the child in a warm bath, which will serve to ditract its attention and at the same time relax the muscular structures. The Rentini symptom, pain around the xiphoid cartilage from gall stones during their expulsion, is deserv ing of particular attention. Vomiting is usually persistent.
Fever, chills, costal respiratory move ments of a jerky character when the pa tient is placed in a sitting posture, are some of the other symptoms that aid in establishing the diagnosis. In young persons jaundice caused by gall-stones without pain is rare. In doubtful cases the urine should be evaporated on a water-bath to about one-tenth its origi nal volume and tested for biliary color ing-matter and biliary salts. Acholic ffeces in children are not necessarily white; frequently they present a green ish color, with putrid odor and diarrhceal tendencies. A. V. Wendel (Med. Hee., July ff. IIS).
Number of successful radiographs of gall-stones obtained. The longer the time of exposure, the clearer the liver and the more obscure the calculi. About five or six minutes gives the best results. The patient should lie upon the abdo men with a pillow underneath his sym physis and clavicles. The rays shall not penetrate the abdomen in a vertical di rection, but should form an angle of about 45 degrees with the plate. A great deal also depends upon the composition of the stone, which is far more complex than that of renal calculi. Calculi con sisting of pure cholesterin give but an indistinct shade, while those containing-. quantities of calcium are well shown. Calculi which consist of a compound of calcium and bilirubin, or carbonic acid, are distinctly brought out by the rays. Carl Beck (N. Y. Med. Jour., Jan. 20, 1900).
Prognosis.—The presence of calculi in the gall-bladder is not of so much im portance when they do not give rise to any pronounced symptoms; but in all cases they are to be looked upon as for eign bodies which may at any time give rise to dangerous symptoms. When phlegmonous inflammation of the gall bladder takes place, the prognosis is grave.
Biliary colic is not always free from danger. Some cases of death from heart failure have been recorded. Distended gall-bladder from calculous obstruction of the cystic duct when accompanied by elevation, and irregplarity of tempera ture, with local pain and tenderness, suggests the possibility of suppuration. Cholecystitis may result in rupture of the gall-bladder or in general septi mmia. Both conditions usually ter minate fatally.
Hepatic and perihepatic abscesses are of grave import. The prognosis of jaundice depends on the amount of ob struction and the previous health of the patient. If the jaundice is intermittent or remittent, as is the case when a cal culus floats in an enlargement of the common duct, the danger is not great, because the system will eliminate the poison in the interval.
If the patient have a poor constitution or if the kidneys are diseased; a mod Prate amount of jaundice may prove serious. The grave symptoms of jaun- : dice are a slow pulse, lethargy, and the occurrence of hmorrhages through the mucous membrane or into the tissues.
Gall-stone operations in jaundiced cases are much more hazardous than those done when that condition is ab sent.
The prognosis of cholelithiasis is nmch more favorable since the develop ment of hepatic surgery, and the experi ence of the last two or three years would seem to indicate that it is possible to remove calculi in the most difficult cases with comparative safety if the patient be not allowed to become too much poi soned by the toxins of bile and by those resulting from membranous infection.
Etiology.—Biliary calculi have been found at all ages, even in newborn chil dren. The fact is well established that cholelithiasis increases in frequency with advancing years. According to Schroe der's statistics as given by Waring, gall stones were present in the following per centages of cases:— Under 20 years, 2.4 per cent.
Between 20 and 30 years, 3.2 per cent. Between 30 and 40 years, 11.5 per cent.
Between 40 and 50 years, 11.1 per cent.
Between 50 and GO years, 9.9 per cent. Over 60 years, 25.2 per cent.
Krauss found in actual practice that gall-stones diagnosed by symptoms dur ing life occurred most frequently in men between the 40th and 60th years, and in women between the 30th and 50th years. Recklinghausen's statistics of au topsies made between 18S0 and 1SS7 give the percentage of all stones: 4.4 per cent. of men and in 20.6 per cent. of women.