bladder region exact decision is impossible. We then rest on the clue whether the arising pain constantly begins in the gallbladder region. It should be remembered that thousands of subjects posses gallbladder calculus, but are not conscious of it. Infection or trauma of the gallbladder initiates violent peristalsis resulting in pain. The presence or absence of temperature may aid as temperature may indicate cholecystitis. Pain subsequent to ingestion of fluid or food may arise in gastritis, ulceration, carcinoma, or arise when food courses through a duodenitis over an ulcer. The pancreas may be affected (though it is the least diseased of all of all abdominal organs). The right ureter may present pain from ureteritis (especially pelvic ureteritis adjacent to duodenum) or calculus. In 1,000 subjects I found that in 9 per cent of males the appendix was non-descended, hence perityphlitis may induce pain in the right proximal quadrant of the abdo ROENTGEN RAY OF DUCTUS PANCREATICUS AND PART OF DUCTUS BILIS. Fig. 3. This rarely instructive specimen contains 4 hepatic calculi in Vater's diverticulum-B, (which had infected the ductus pancreaticus). The Hofman-Wirsung duct was extensively dilated. The ductus pancreaticus at C and D, contained hepatic calculi. The ductus choledo chus communis was dilated over three-fourths inch in d'ameter and the pancreatic duct one-third larger than the normal. C, cholecyst, contained no calculus. This specimen demonstrates that hepatic calculus may become located in any segment of the biliary ducts, e. g., the elephant possesses no gallbladder, yet enormous hepatic calculi arise in his biliary ducts. The deer, camel and horse possess no gallbladder. I secured this specimen at an autopsy with Prof. W. A. Evans. men. subjects) may induce pain by compromising visceral peristalsis I have demonstrated for 15 years. However, though the chief adhesions. adjacent to the gallbladder, duodenum, colon and omentum are due to leakage from the biliary passages, yet abundant adhesions arise from leakage from the duodenum, ureteral pelvis, colon, gastrium, to make diagnosis uncertain. I have demonstrated in autopsy that the kidney is adherent to the distal surface of the liver in 40 per cent of adults-the kidney and liver moving as one viscus. Hence, pain as a symptom of gallbladder calculus is accompanied by numerous complicated and conflicting factors. The diagnosis of gallbladder calculus resting on pain must be made by the idea that "probability is the rule of life." As to physical symptoms, the diagnosis of gallbladder calculus is accompanied with many uncertainties. Tumors of the right kidney are the most confusing. I have spent a week to decide whether a patient possessed an enlarged gallbladder or an enlarged, excessively mobile. right kidney. The cystoscope furnished no aid. The X-ray revealed the preponderating clue from location and contour in favor of the enlarged gallbladder, which proved correct. A kidney tumor is universally movable, with renal In diagnosing gallbladder calculus we are practically diagnosing cholecystitis. Thousands of hepatic calculi exist without pain and autopsy alone exposed them. Inflammation of the biliary passages is required for pain. However, a sudden violent engagement of a calculus will incite painful peristalsis. It should be remembered that numerous closely adjacent viscera complicate location of pain, and especially when the provoked pain is of similar characterit is the colicky pain, the peristaltic pain of hollow viscera. With the abdominal wall incised and the viscera exposed a silver dollar will include an area of a number of different important viscera, viz: pylorus, gallbladder, Vater's diverticulum, duodenum, head of pancreas, right colonic flexure, ureteral pelvis, and perchance the appendix. In closely adjacent viscera, performing different functions, however, presenting similar colic or peristaltic pains, differentiation can only be estimated a preponderating balance favor. That adhesions adjacent to gallbladder, duodenum, colon, omentum and kidney (bound to liver in 40 per cent of PANCREATIC CALCULI. Fig. 6. This illustration presents a rare specimen of numerous pancreatic calculi-of maximum dimension, and located throughout the length of the ductus pancreaticus. Biliary ducts appeared negative. V. P., hypertrophied Vater's papilla. H-W, D. Hofman-Wirsung duct. (Drawn from specimen in Rush Medical College by courtesy of Prof. Le Count.) form, while an enlarged gallbladder moves mainly transverse and is non-renal in form. The above patient's attack resembled both hepatic calculus and ureteral calculus. The connection of the tumor with the liver may aid in the diagnosis. Also the decision must be made whether the enlarged gallbladder or movable kidney is responsible for the pain. Tumors of the pancreas, pylorus, gastrium, colon, omentum, may be mistaken for the gallbladder. Autopsy demonstrates positively that the vast majority of gallbladder calculus cannot be palpated. It is common in autopsy or sectio in vivo to discover gallbladder calculus of which the patient or physician never suspected. The symptoms peculiar to each variety of pathology of the different viscera in the right proximal quadrant are insufficient to make a differential diagnosis. Rupture of an inflamed gallbladder cannot be diagnosed from perforation of the gastrium, duodenum or appendix. In fact, it is frequently impossible to ascertain whether the gastrium, duodenum or appendix is at fault. Cholecystitis is less sudden in its beginning than hepatic calculus. In every diagnosis of gallbladder calculus perityphlitis must be maintained in view, as the appendix may be non-descended and the gallbladder may rest in the iliac fossa-both acute infection of these organs presenting almost identical symptoms. Hence, the location. of pain in gallbladder calculus cannot serve as an infallible guide. It would seem, however, that pain from the gallbladder directed itself Fig. 5. This figure represents the nerve apparatus which controls the physiology of the organs in the proximal abdomen. It illustrates at a glance the difficulty of differential diagnosis among numerous organs supplied by nerve plexuses radiating from the same center (the abdominal brain). Observe the rich nerve plexuses radiating to the liver, spleen, stomach, duodenum, kidney from the nerve center-the abdominal brain. The abdominal brain preserves the equilibrium of function in the proximal abdomen. It accounts for innumerable nervous or functional disturbances. more dorsally, while the pain from perityphltitis directed itself more ventrally. It is observable that in acute perityphlitis the beginning pain is more violent and sudden, with more rapid peritonitic symptoms than in cholecystitis. Perityphlitic symptoms, in short, are more pronounced than cholecystitic symptoms. I claim that acute perityphlitis and cholecytitis frequently present such identical symptoms that the differential diagnosis is mere speculation-yea, it is similar even with a state of supervening abscess. I have observed subjects during ample time with icterus, pain in dorsum, nausea, and palpable mass and diagnosed cholecystitis calculosa, to find an exploration, a fist-sized carcinoma, in the lesser gastric curve. Though Dr. Brin has presented excellent views in regard to the varied pathologic condition of the gallbladder and adjacent viscera, I cannot agree on the apparently excessive number of exploratory and conformatory peritonotomies he advocates. I think with ample viscera drainage many of these cases become symptomatically well. Practically it is cholecystitis that we diagnose, and repeatedly for years, with visceral drainage, i. e., two quarts of extra fluid daily containing stimulants for the intestinal and urinary tracts, I have seen many subjects become symptomatically well. However, with preponderating symptoms of cholecystitis calculosa I suggest cholecystotomy and a couple of weeks' drainage of the gallbladder. In conclusion, I wish to remark that the diagnosis in the proximal half of the abdomen is in a state of development-that of the gallbladder and biliary ducts. being the most solidly established. As regards the diagnosis of gastro-duodenal ulcer, it is uncertain and too damaging as to function and structure in its curative methods (gastroenterostomy). The symptomatology of gastric or duodenal ulcer is insufficiently established for positive diagnosis. At present it is not only an exploratory peritonotomy, but also experimental operative procedures are applied. Gastro-enterostomy for gastric or duodenal ulceration is a maximum operation (in physiologic damage) for a minimum lesion. As to the diag nosis of pancreatic disease, what one surgeon in a hundred-who knows not the pathology of the dead-can recognize pancreatitis? CARCINOMA OBSTRUCTING COMPLETELY THE BILIARY AND PANCREATIC DUCTS TWO INCHES DISTANT FROM VATER'S DIVERTICULUM. Fig. 9. An x-ray as a sketching model. The ductus bilis (except the cholecyst) was dilated to a capacity of 32 ounces or some 6 or 7 times the normal capacity. The cholecyst was dilated about 4 times the normal capacity. The ductus choledochus was 14 inches in diameter. The pancreatic duct would admit the index finger. T, represents the carcinoma divided by the scalpel. The ductus choledochus communis and ductus pancreaticus located between the carcinomatous mass and Vater's diverticulum were normal. The man, 50 perhaps, lost in weight about a hundred pounds during the last three months of his life. I secured this specimen at an autopsy with Charles O'Byrne. In court testimony we are compelled to announce that many of the diseases of the proximal right quadrant of the abdomen are diag nosed ultimately by an exploratory and confirmatory perotonotomy. THE COMPRESSIBLE TUBE TREATMENT OF GONORRHOEA.* By DR. WM. KARO, Berlin, Germany. In the local treatment of gonorrhoea by the introduction of medicaments into the urethra, our efforts have heretofore been directed towards the use of aqueous solutions in the form of ordinary injections and to the application of oily or fatty substances in the form of suppositories, fat bougies, etc. With these forms of treatment we have accomplished our results, we can also say our bad results. The scientific rationale of these *Translated from the German by H. J. Scherck, M. D. methods is important enough to give a brief outline at this time. As to the treatment of gonorrhoea with aqueous solutions in the form universally used, injections, there is a unanimity of opinion that their use for centuries carries with it innumerable objections. I would like especially to point out how uncomfortable and impracticable this is for the majority of patients especially for workmen and travellers, requiring as it does the use of special apparatus; syringes, medicine bottles, and beakers in which to pour out the solution; a procedure, which for many patients makes the proper carrying out of the injection treatment impossible. I do not intend here to dilate on the many attempts to simplify and modernize the injection treatment, since the use of aqueous solution is complicated with so many side issues. One of the paramount issues is the fact that the medicament remains entirely too short a |