Gallstone

“ But Nature is consistent. Appendicitis and gallstones lie in wait for him; ulceration and cancer of the stomach, diabetes, Bright’s disease, rheumatism, gout, asthma, dropsy, apoplexy, etc., are at the other end of his path, and if one of them does not attack him soon, another will later. The danger of living lies in eating. To die of one of these diseases, or to require an operation for appendicitis or gallstones ought to make the victim ashamed of himself. ”

“ Irritation caused by the consumption of alcoholic beverages seems, in certain countries in which cancer of the stomach is more frequent in men than in women, to be one of the causes of gastric carcinoma. In the intestines cancer is frequently preceded by the formation of papillomata which again are in most cases the result of chronic irritation and inflammatory processes. Cancer of the gallbladder is more common in women, because women more than men are, as a result of certain habits, prone to suffer from gallstones, and gallstones cause a condition of constant irritation in the gallbladder. ”

“ There are no absolutely diagnostic symptoms, but should one find a horse that suffers from repeated attacks of colic, accompanied with symptoms of violent pain, and that during or following these attacks the animal is jaundiced, it is possible that gallstones are present. There is little or nothing to be done except to give medicines to overcome pain, trusting that these concretions may pass on to the bowels, where, from their small size, they will not occasion any inconvenience. ”

“ He was elected a fellow of the College of Physicians 30 Sept. 1796, and in 1799 delivered there the Gulstonian lectures. They were published in 1800, under the title of ‘Observations on the Bile and its Diseases, and on the Œconomy of the Liver,’ and show careful observation and sound judgment. The method of clinical examination of the liver which he proposes is excellent; and he is the first English medical writer who demonstrates that gallstones may remain fixed in the neck of the gall-bladder, or even obliterate its cavity, without well-marked symptoms or serious injury to the patient. ”

“ Even death itself has resulted from the impaction of a gall-stone in the duodenum. When we have any suspicion that the stone is large, our treatment must therefore be continued until its extrusion by the mouth or rectum has been accomplished.
When the occlusion of the common bile-duct is caused by an organic tumour, no treatment of ours can be expected to remove the obstacle, and sooner or later the patient is carried to an untimely grave. Our efforts of relief in such a case ought therefore to be directed to another channel ”

“ Impaction of the bowel by gall-stones escaping from the gall-bladder into the bowel is by no means an unfrequent cause of fatal obstruction. Small gall-stones, after giving rise to intense pain and often grave symptoms during their passage through the bile-ducts, may escape into the duodenum and be discharged through the rectum, as any other small foreign body. If, however, there is constriction or stricture of the bowel at any point, the small gall-stone may lodge there, and if other stones follow and lodge, the collection may soon be great enough to produce obstruction. ”

“ If the stone happily finds its way into the intestine the distress suddenly ceases. In the meanwhile relief may be afforded by fomentations, and by morphia or chloroform, but if no prospect of the stone escaping into the intestine appears likely, the surgeon will be called upon to remove it by an incision through the gall-bladder, or the bile-duct, or through the intestine at the spot where it is trying to make its escape. Sometimes a gall-stone which has found its way into the intestine is large enough to block the bowel and give rise to intestinal obstruction which demands abdominal section. ”

“ It is thus seen how in permanent occlusion of the common gall-duct the liver may be found hypertrophied in the first, of normal dimensions in the second, and atrophied in the third and last stage of the disease.
In cases of the kind here described, it is not at all unlikely that the enlargement of the liver in the earlier, as well as its atrophy in the later [p. 49] stages of obstruction, may be mistaken for the cause of the jaundice, instead of the result of the arrest of the flow of bile, and thereby lead to a grave error in treatment. ”

“ Biliary concretions, known as gall stones, are apt to form in the gall-bladder. They are composed of crystals of bile-fat, cholesterine. Sometimes in the course of a post-mortem examination a gall-bladder is found packed full of gall-stones which during life had caused no inconvenience and had given rise to no suspicion of their presence. In other cases gall-stones set up irritation in the gall-bladder which runs on to inflammation, and the gall-bladder being infected by septic germs from the intestine (bacilli coli) an abscess forms. ”

“ Cholelithiasis, that is, stone in the bile duct, may not only cause severe pain, but may lead to rupture of the duct and a rapidly fatal termination. Owing to the practice of wearing corsets, gall-stones occur much more commonly in women than in men. Twenty-five per centum of all women over 60 years of age are found to have gall-stones. While these cases suffer from intense pain they are very seldom fatal. But it must not be forgotten that a fatal issue can take place either from collapse and stoppage of the heart, because of the intensity of the pain, or from perforative peritonitis. ”

“ Gall-stones infest more the adult, old, and sedentary; and it is alledged, more females than males. The symptoms at first are dubious, and are all to be weighed together in forming a diagnostick. In attempting to descend throughout the gall-ducts, they excite direful pain at the pit of the stomach and hepatick region, darting to the back, with restlessness, anxiety, dyspnœa, jaundice-colour of the eyes, costiveness, and commonly vomiting: the pain is aggravated by coughing or sneezing, and sometimes ascends to the right shoulder and arm; but the pulse and circulation are not accelerated. ”

“ In some cases the pain comes every few weeks and then may be scattered, sometimes seeming to be in the stomach, and then in the bowels, or in the region of the liver. When a person has such pains and locates them in the stomach or bowels, and they come periodically, every week or two or more, he ought to be suspicious about it being gall stones, especially if the symptoms do not show any stomach trouble. If the stone is large and closes the common duct, jaundice occurs; the stools are light colored; the urine contains bile. ”

“ I must here mention, that jaundice does not necessarily follow upon absence of the gall-bladder; just as in the horse, the deer, the rat, and other animals that possess no gall-bladders, the biliary function is perfectly well carried on, so it may be in the human subject, labouring under a congenital or accidental deficiency of the gall-bladder. In such cases, the hepatic ducts are pervious, and consequently the secreted bile finds no difficulty in reaching the intestines. ”

“ The symptoms and signs of secondary carcinoma or sclerosis of the liver may be present, but the most commonly observed indications of impaired hepatic function depend upon pressure-obstruction of the common bile-duct. These are jaundice, fatty and clay-colored stools, and the appearance of a tumor in the region of the gall-bladder. Jaundice is a very common symptom. It occurs late in the disease as a rule, is progressive and persistent, resisting all treatment, and is extreme in degree, the skin becoming deep-yellow or greenish in color. ”

“ In women gall-stone disease is more frequent than in men. This depends upon the greater frequency of diseases of the thyroid and sexual glands in women. Changes in the sexual organs produce an irritation of the splanchnic with checking of the peristaltic movements of the intestine and, at the same time, relaxation of the muscular coat of the bile-ducts. Thus there arises a deficient expression of bile, and stagnation follows, with invariable immigration of bacilli producing inflammation and precipitation of cholesterin and gall-stones. ”

“ When once a gall-stone has formed, and is blocking up the common bile-duct, thereby causing jaundice from obstruction, it is easy enough to understand why a substance like podophyllin, which increases the biliary secretion, is to be avoided. It is not, however, so easy to understand why the remedy is equally counter-indicated, either during the formation or sojourn of a gall-stone in the gall-bladder. ”

“ In case of jaundice, the bile, which is perhaps not at all absorbed in a state of health, is taken up in large quantities, and mingled with the mass of blood, which proves a seasonable relief in the state of accumulation and distension occasioned by the obstruction. This may happen in cases of fever, not indeed as a relief to nature, but from a depraved state of irritability in the lymphatics, induced by disease. Though no increased quantity of bile, therefore, is found in the gall bladder, there may have been an increased excretion of it, a preternatural absorption having been excited. ”

“ Not a few may also be found in the intestinal canal and in the excrement about to be voided. Occasionally dead specimens become surrounded by inspissated bile, and gritty particles deposited in the liver ducts, thus forming the nuclei of gall-stones. Mr Simonds mentions a remarkable instance, “where the concretion was as large as an ordinary hen’s egg, and when broken up was found to contain about a dozen dead flukes. It was lying in a pouch-like cavity of one of the biliary ducts.”
In respect of treatment we all know that “prevention is better than cure.” ”

“ A gentleman, aged fifty, who had been a remarkably healthy man, observed, within eighteen months of his death, that his skin gradually assumed a more and more jaundiced tint without any assignable cause. The stools were clay-coloured, the urine loaded with bile pigment. Soon afterwards, the patient began to lose flesh. The liver became enlarged, and somewhat tender to the touch; the gall-bladder being at the same time so distended that it could be seen, as well as felt, projecting from under the false ribs. ”

“ When the number of bacteria in the intestines is much greater than usual, certain dangers arise from such a condition, as thereby the immigration of bacilli into the bile-duct is facilitated causing inflammation of the gall-ducts and gall-bladder, and subsequently gall-stone disease. Further consequences of such a condition may be the closure of the bile-duct, and then no bile can reach the intestines. The presence of bile, however, is very important, for, according to current opinion, this exerts an influence on the checking of putrefaction in the intestines. ”

“ The whole duration of the disease was merely six days, and the more urgent symptoms only manifested themselves two days before the fatal termination.
After death the liver was found to be very small in size, not exceeding, as was supposed, 11⁄2 pound in weight. It was deeply stained yellow, and its cells were found to be small, and broken up; not an entire cell could be detected by either Dr. Wilks or myself—nothing, indeed, but a quantity of débris of hepatic tissue, and fat. The gall-bladder was contracted, and contained only a little mucus; the urinary-bladder was empty. ”

“ There are some authors who say that the gall exists in the horse, not in the liver, but in the paunch, and that in the stag it is situate either in the tail or the intestines; and that hence it is, that those parts are so bitter that dogs will not touch them. The gall, in fact, is nothing else but the worst parts of the blood purged off, and for this reason it is that it is so bitter: at all events, it is a well-known fact, that no animal has a liver unless it has blood as well. The liver receives the blood from the heart, to which it is united, and then disperses it in the veins. ”

“ When the gall-bladder is distended with gall-stones, or is in the enlarged state which occurs when the common duct is obstructed, it may project beneath the inferior border of the liver far enough to be felt. In thin persons a grating sound, produced by the friction of the calculi, may be heard, the stethoscope being applied as palpation is made over the hypochondrium. It is rare that these symptoms can be elicited, since the calculous affection of the liver occurs for the most part in persons of full habit, in whom the abdominal walls are too thick to allow of the necessary manipulation. ”

“ It is true that occasionally the intestinal irritation due to the presence of these bodies in some instances preceded the symptoms of impaction, but usually there is no evidence to indicate that the stoppage of the bowel is due to anything else than feces. The irritability manifested by the intestinal mucous membrane when gall-stones are present varies remarkably. There may be only some ill-defined pain which, as a rule, indicates the position of the calculus, or it may be pain with a feeling of soreness, or it may take the form of violent colic, with nausea, vomiting, and depression. ”

“ Also, in the matter of the yellow bile, he makes an even grander and more spirited venture; for he says this is actually generated in the bile-ducts, not merely separated out. How comes it, then, that in cases of jaundice two things happen at the same time—that the dejections contain absolutely no bile, and that the whole body becomes full of it? He is forced here again to talk nonsense, just as he did in regard to the urine. He also talks no less nonsense about the black bile and the spleen, not understanding what was said by Hippocrates ”

“ If the spleen become affected with any disorder, so that it cannot separate the black bile from the blood, such diseases as leprosy, insanity, inflammation of the spleen and remittent fever are the consequence. If any derangement happen to the gall-bladder so that it cannot secrete the bile, bilious disorders follow. If the kidneys get disordered, so that they cannot abstract the water from the blood, dropsy and similar diseases are the result. It all depends, however, on the will of God. In the same manner, all the organs of the body have a specific function. ”