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Dr. Howard Lilenthal presented a woman, thirty-four years old, who was admitted to Mt. Sinai Hospital on the 8th of May last. She had never had any symptoms pointing to gall bladder disturbance until two weeks before, when she complained of severe abdominal pain, especially in the right hypochondrium and extending through to the midscapular region. These pains subsided after two or three days, but returned after an interval of two days. During the two weeks previous to her admission to the hospital she had had several similar attacks. She had never been jaundiced ; she had no chills, but thought she had been fever ish. The bowels were regular ; there were no urinary symptoms.

An examination at the time of her admission showed that her general condition was good. There was no icterus. There was marked congestion over both lower lungs. There was a systolic murmur at the apex and the second pulmonic sound was exaggerated. There was dulness in the right flank. The region of the appendix and gall-bladder could be palpated without elicit ing much pain. No distinct mass could be felt and no free fluid could be made out by the physical signs. The liver percussed below the free border of the ribs. The temperature was F. ; pulse, 140. On the following day the temperature had risen to 103.4°, and slight conjunctival icterus was noted.

May 14, Iwo, through a large abdominal incision, the gall bladder was found pretty well under the liver, so that it could hardly have been palpated in so stout a patient. It was tense and apparently filled with stones. On account of the practical ab sence of icterus, and because of the apparent absence of stones in the common duct on palpation, Dr. Lilienthal determined to remove the gall-bladder, which was evidently diseased to such an extent that it could not have been expected to functionate normally again. The excision of the gall-bladder was done by encircling the cystic duct with a stout silk ligature, which was then tied very tightly, and the ends of the ligature were allowed to protrude through the wound. The liver attachment of the gall-bladder was pretty broad, and was secured by two long uterine clamps placed parallel to each other, one on each side of the attachment. The gall-bladder was then excised and the clamps left in situ. Most of the wound was closed, with drain age. Seven hundred and sixty-two stones were found in the gall-bladder. These were exhibited by Dr. Lilienthal.

The patient reacted rather poorly from the operation and required active stimulation. Her temperature rose to 104.6°, and signs of pneumonia were detected at the right apex. The con gested condition of the lower lungs which had been noticed at the time of her admission had in the mean time disappeared. The clamps were removed two days after the operation, and this gave rise to no haemorrhage. Her temperature gradually fell with the disappearance of her pulmonary symptoms, but on the fifth day it rose again and remained elevated for a few days ; this was probably caused by a stitch suppuration due to a slough ing superficial wound of the abdominal wall which had resulted from the application of an ice-bag previous to her arrival at the hospital.

On May 26 the sutures were removed. There was practically no discharge from the wound. The patient was out of bed on June 7, but she was kept in the hospital until the fifth of the following month before the silk ligature with which the cystic duct had been tied off could be removed. In a similar case since then, Dr. Lilienthal said, he had employed chromicized catgut for this purpose with much more satisfactory results.

gall-bladder, temperature, hospital, wound, days and lilienthal