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 |   Related post: pressure with the finger tips is made. These ma- neuvres will enable one to be reasonably sure of the presence of tenderness. Occasionally, in long standing cases of chronic cholecystitis a tongue- like lobe of the liver overlying a tender gallbadder can be made out by palpation and percussion ; also a circumscribed rigidity of the overlying abdominal walls may be present, which, together with the above mentioned signs, makes the diagnosis more certain. The chief error in many cases, however, is failing to rule out a diseased appendix that holds a high position. Again let me say that the appendix can be likened to the protean artist who is capable of assuming many different characters at will. The avoidance of error in the differentiation be- Purchase Phenytoin Online tween chrcinic appendicitis, where the appendix holds a high position, chronic cholecystitis, chronic pancreatitis and chronic atypical duodenal or gas- tric ulcer is many times impossible, with the ex- ception perhaps of the ulcer cases, in which the X ray should settle the diagnosis, although that too has been known to fail. Stomach analysis is anything but trustworthy, yet it should neverthe- less be made for occasionally it is of diagnostic value. In doubtful cases we naturally take advan- tage of every means at our disposal and then fail 52 DEAVER: ERRORS IN ABDOMINAL DIAGNOSIS. [New York Medical Journal. often enough, and even with the belly wall laid open, how often have I had difficulty in arriving at a definite conclusion. Typical chronic duodenal or gastric ulcer with few exceptions ought not be overlooked. The history of indigestion with epigastric fullness, to the extent of producing a feeling as if the stomach v>^ould burst, pain coming on two, three or four hours after eating, depending upon whether the lesion is gastric or duodenal, usually relieved by eat- ing or by taking bicarbonate of soda ; the high acidity, the periodicity of the attacks of pain, the X ray findings, which are usually positive, should make the diagnosis. The heavier the meal the longer will the pain and feeling of fullness be in appearing. The interval between attacks leads the patients to believe that they have been cured. It is important to remember that an excess of total acidity, with a high free hydrochloric acid, and hunger pain also occur in cases of chronic gallstone disease. When the x ray does not show ulcer or gallstones it frequently will show adhesions which of course mean a lesion ; the most common factor in the upper right abdomen responsible for Buy Cheap Phenytoin adhe- sions being a chronically infected gallbladder. A high appendix which has been the seat of a terminal inflammation is also responsible for a con- siderable percentage of the cases in which adhe- sions are found. Adhesions are the aftermath of a peritonitis, that is, where there are adhesions there has been a peritonitis although it need not necessarily have been severe enough to have been recognized as such. Adhesions hold the same rela- tion to a previous peritonitis as smoke or charred wood to a previous fire, where these are found there is or has been a fire. I hope I may be per- mitted to repeat what I have so often stated that most of the adhesions I have had to deal with have been pathological and not congenital. My experi- ence in having opened many thousands of peri- toneal cavities in Order Phenytoin all stages of inflammation has forced me to this conclusion. It is only those of us who have many times observed in the living autopsy Buy Phenytoin Online peritonitis from its earliest to its latest and terminal stages that are best capable of passing final judgment on this subject. Adhesions indeed often play a prominent role in chronic abdominal disease and are very frequently responsible for errors in diagnosis. The experience is not uncom- mon after an elaborate diagnosis to find that the patholog}- is due to adhesions alone. If a patient past middle life, without a history of indigestion, suddenly loses appetite, especially for meats, grows progressively weaker and more emaci- ated, develops epigastric pain and possibly a pal- pable mass : if in addition he becomes subject to vomiting spells every few days which bring up a quantity of coffee ground material, foul smell- ing and fermented, and the cancerous cachexia quickly develops, we have the classical picture of gastric carcinoma. It is still frequently seen, but it is rare when compared with the other course of development which we have begim to appreciate only in the last few Buy Phenytoin years, — as found in lifelong suflFerers from dyspepsia. Medical treatment Order Phenytoin Online has at times given relief, but the indigestion recurs again and again. Appetite may be preserved, but digestion is torture; so that abstemiousness becomes second na- ture. There may or there may not have been some period when gastric ulcer was suspected or actually diagnosticated. Usually there have been no very definite symptoms, and the patient has been treated for chronic gastritis. Finally the patient dies, and at autopsy a widespreading epitheliomatous ulcer ;s found. Gastric carcinoma appears with sudden onset in not more than ten per cent, of cases. The greatest good can only be obtained by operat- ing early for rebellious indigestion and not waiting until there is no longer any question that the patient has carcinoma. The error of failing to recognize chronic pancre- atitis is a common one. While it is true that it is difficult to make the diagnosis, this is no ex- cuse for failing to think of this by no means un- common condition and in endeavoring to recognize it. A history of longstanding gallbladder disease m the shape of the premonitory symptoms of gall- stone formation, namely, fullness after eating, eructations of gas, occasional nausea, epigastric discomfort, occasional yellow tinge of the sclera, slight fullness to palpation in the epigastric region, with, in some instances, palpatory evidence of an enlarged pancreas ; if in addition the urine shows a positive Cammidge reaction and, more Purchase Phenytoin especially, if free fat is found in the stools and there is likewise a history of large bulky stools — all these symptoms and signs warrant the assumption of bome pancreatic disturbance. Most often, however, the condition should have Generic Phenytoin been detected in its early stage of a pancreatic lymphangitis which gives rise to practically the same type of symptoms as in chronic pancreatitis. It is the inexcusable sequel of neglected gallbladder disease, and failure to recognize it provides much of our operating material. 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