. Lectures on the diagnosis of abdominal tumors, delivered to the post-graduate class of Johns Hopkins university, 1893. from the effects of lacing, butit is directly caused by traction, the gradually distendinggall bladder elongating the anterior margin. In twelve ofthe cases upon which Riedel operated this tongue-likeprocess was present ; in nine in-stances the gall bladder was pal-pable either at the median or un-der margin of the process. InCase XXXVIII I believe this pro-cess is present. It is not always,however, associated with dilatedgall bladder, and I have seen verycurious elongations
. Lectures on the diagnosis of abdominal tumors, delivered to the post-graduate class of Johns Hopkins university, 1893. from the effects of lacing, butit is directly caused by traction, the gradually distendinggall bladder elongating the anterior margin. In twelve ofthe cases upon which Riedel operated this tongue-likeprocess was present ; in nine in-stances the gall bladder was pal-pable either at the median or un-der margin of the process. InCase XXXVIII I believe this pro-cess is present. It is not always,however, associated with dilatedgall bladder, and I have seen verycurious elongations of the anteriormargin of the right lobe in per-fectly normal livers, and in severalinstances of the posterior marginof the left lobe. It is importantto recognize the existence of thisprocess as it may form a verydefinite mass in the right very interesting instance of itwas referred to me by Dr. WeirMitchell two years ago. An extremely nervous woman,aged about fifty-six years, had had for several yearssymptoms of neurasthenia, pains in the abdomen, andill-defined manifestations, for which she had sought re-. Fio. 32.—The tongue-shaped ex-tension of the anterior marginof the right lobe, with the gallbladder projecting below it.(Riedel.) 112 THE DIAGNOSIS OF ABDOMINAL TUMORS. lief in many quarters. In his note to me Dr. Mitchellstated that there was a tumor of a doubtful nature inthe right flank. I saw the patient with her relative The only interest in the case is in the examina-tion of the abdomen. Just beneath the right costal mar-gin, extending toward the anterior superior spine, was anelongated mass with very ill-defined borders. The fingerscould not be inserted beneath it, nor was there a definiteedge palpable. It was tender on pressure, not movable ina lateral direction, but with the fingers deep in the flankbehind it could be tilted forward. It did not seem to becontinuous with the liver, the dullness of which terminatedjust below the costal margin.
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