Cholelithiasis.

By E. H. Martin, M. D., Middlebury, Vt.

A woman, forty years of age, previously in good health, famous in her social circle as a cook, and demonstrating in her plump, solid physique her love for the good things of the cuisine, was suddenly and without warning attacked, late one evening, by a most excruciating pain. So intense and prolonged was her suffering that the doctor, hastily summoned from several miles away, found her writhing and tossing upon the bed in what is, without doubt, one of the most extreme forms of agony to which the human frame can by any form of disease be subjected. The pain, markedly paroxysmal in character, was referred to the epigastrium, and the stomach, reflexly irritated by the disturbance of a closely-related viscus, showed its sympathy by first emptying itself of its contents and then by repeated and well-nigh fruitless attempts at vomiting, which resulted only in the ejection of its scanty mucous secretion. The feeble pulse, the anxious countenance, the pitiful moans of the unhappy sufferer, the clammy perspiration and the cold extremities served to complete the clinical picture of suffering even to the verge of collapse. Only by the free and oft-repeated hypodermic use of mor

phine were the severe symptoms alleviated, until, finally, after many days had elapsed, the pain and the nausea quite suddenly disappeared. The epigastric region remained sore, and close examination would have revealed the acme of tenderness in the angle formed by the right border of the right rectus abdominis and the costal cartilages. She was finally able to be about the house in a condition of comparative health for about two months, when, as suddenly as before, there was an exacerbation of all the symptoms exactly similar to the original attack; and again with the lapse of time the sufferer's condition became ameliorated as before. Finally, after a second remission of several months' duration, the original symptoms suddenly for the third time reappeared with appalling severity, and a few days later a new and extremely suggestive feature made itself apparent in a yellow discoloration of skin and conjunctivæ, clay-colored stools and bilious urine-the symptom-complex of jaundice—and now percussion demonstrated the liver markedly enlarged. Once more as days passed her condition became alleviated and a very little bile was occasionally visible in the dejecta, although the jaundice persisted and she was still confined to the bed. About four weeks after the occurrence of the jaundice and at a time when her condition had become comparatively comfortable save for the lingering, sub-acute pain and tenderness, she turned over in bed, became unconscious, breathed stertorously a few times and expired.

The necropsy revealed the following conditions: The body, although materially reduced from its former robust and plethoric state, was still well nourished and the abdominal parietes contained adipose tissue two inches in thickness. The liver was uniformly softened and enlarged

and extremely adherent by its under surface to the adjacent structures. No traces of the gall bladder or ducts were visible as separate structures-they being obliterated and covered up by the mass of adhesions. Upon carefully separating the adherent organs the common duct was torn across and from its lumen oozed abundant brownish opaque bile, and as it ran out it brought with it several concretions of small size. The gall ducts were uniformly dilated, so that a finger could be readily passed into them. There were eleven stones, faceted and of the usual color. Of these, two or three of the largest were of the size of a Delaware grape, and one of these was found at the duodenal extremity of the common duct, not impacted, but forming a ball valve over the normally-sized and pervious opening into the gut. The other abdominal and thoracic organs were normal, except that the heart and blood-vessels were in a condition of extreme fatty degeneration. A finger could be readily thrust through the cardiac walls. The brain was not examined and the immediate cause of death was not found, but the condition of the blood-vessels and the manner of death unmistakably suggested cerebral hemorrhage.

It must not be supposed that the details of the case just considered have been rehearsed on account of any very remarkable or unusual features which it possessed. On the contrary, the sex, age, physique and habits of the patient, the successive attacks and sudden onset of pain, its paroxysmal character, even the time of day of its occurrence, the absence of fever, the location of the tenderness, the nausea and vomiting, and, finally, the jaundice and hepatic enlargement form a clinical picture the significance of which could hardly be misinterpreted and which should scarcely require

an autopsy for confirmation. As regards the post mortem appearances Fenger, at the meeting of the American Medical Association last summer, said in his paper on "Gall Stones in the Common Duct": "In the majority of cases these are floating stones and they sometimes act as a ball valve. In eighty per cent of these cases we find, instead of a dilated bladder, a small atrophied one "—exactly the condition in the case under consideration. The very fact of the absence of unique characters has suggested its introduction, that it may stand as a type of a very common condition, which in its essential features must often occur in the experience of every practitioner. If any further excuse be needed, let it be found in the fact that this very case was variously diagnosticated as gastralgia, gastritis, lead colic, peritonitis and cancer, and the real nature of the disease not perceived till within three weeks of death.

Looking at the symptoms pointing so obviously to the condition causing them and keeping in view the findings of the post mortem, let us enquire, What was the sequence of pathological events which led to so unfortunate a termination?'' In the absence of positive knowledge of the etiology of gall stones it is only possible to hint at the methods of life and the sedentary habits which may have formed the first step in the process, but, given the concretions already formed in the gall bladder, one of them of small size became engaged in the cystic duct. Immediately the suffering began and the intermittent, peristaltic muscular action of the gall bladder gave to the pain its paroxysmal character. Slowly the calculus passed through the cystic duct until it escaped into the common duct. The latter being of larger size, the stone rapidly traversed its lumen and dropped into the duodenum without having time to cause the symptoms

of jaundice-a condition which requires several days for its appearace. Of course the impaction and retention of a concretion in the cystic duct produces no obstruction to the outflow of bile from the liver and hence no icterus. Such was the nature of the first attack, and the second was similar to it. The third and last attack was caused by the larger stone found at the autopsy, which entered a cystic duct quite possibly left more patulous by the passage of the first calculi. Reaching at length the common duct, and here giving rise to obstructive jaundice, it passed slowly along until it became arrested at the constriction marking the opening into the duodenum, and now the duct having been fully dilated and no longer tightly grasping the concretion, the pain ceased, but the stone, held against the duodenal opening by the pressure of the retained bile, formed a valve, which, however, was not quite perfect and allowed the occasional passage of the small amounts of bile seen in the dejecta. In the meantime, the other stones having followed in the wake of the leader, the emptied gall bladder became atrophied, and the local peritonitis set up by the great and long-continued irritation glued all the contiguous structures into a mass of adhesions. Finally an acute fatty degeneration of the heart and blood vessels, which is a not infrequent sequel to such cases, paved the way to the last and fatal event.

And now let us pause to consider what should have been the treatment of this case—what might have been done to bring it to a happier issue. The symptoms of gall stones before one of them has started on its travels are indefinite or nil. The unlucky patient, suffering no inconvenience, had no suspicion of her impending fate and consulted no physician, and even a physician would have been without a clue. No method of examination short of actual incision could