Cholelithiasis.
Synonyms:—Gall stone: biliary calculi.
Definition:—A condition in which concretions are formed in the gall-bladder, which may become lodged in the biliary passages, or which, in passing through the duct, induce pain and inflammation.
Etiology:—Conditions which predispose to catarrh, not only of the lining of the gall-bladder, but of the duodenum and stomach as well, lead to the formation of these concretions. They are apt to appear in corpulent persons and in those who are addicted to high living, with the use of sweet wines or beer, or who live an inactive, a somewhat sedentary life. It occurs more frequently in women than in men, in the proportion of three to one, and more commonly in women who have borne children. It rarely occurs in childhood. It is supposed to be induced by dietary faults, irregular eating, tight lacing, constipation, or the presence of foreign bodies in the abdomen; all of which induce catarrh or obstruct the flow of the bile. It is more common after middle life, between forty-five and sixty years of age.
Because gall stones are frequently associated with fevers of an infectious origin and because various micro-organisms are found at times in the gall bladder, the theory has now become firmly established that these micro-organisms form with the epithelial cells a nidus around which the biliary substances deposit by agglutination. The most common of these are the typhoid bacillus, the pneumococcus, the colon bacillus, the staphylococcus, and the streptococcus. Experiments performed by Gilbert, Fournier and others who have observed the formation of gall stones in animals, after micro-organisms were injected into the gall bladder, have confirmed this opinion. It is necessary that the mucous membrane of the gall bladder be in an unhealthy condition to permit the development of these concretions, else there would be no secretion of the constituents of which the gall stone is formed. These constituents are cholesterin, mucus, and a pigment lime, which is called bilirubin calcium.
When gall stones are soft they are composed of cholesterin and mucus, they are white or yellowish white in color, and may cut like hard cheese or a piece of wax. When the bile pigment is present in their constituency and earthy salts are deposited, they may be hard or brittle and gritty. These are much darker in color, having a light brown, or dark brown, or brownish green tinge. It is seldom that a single stone is found in the gall bladder, with no other concretions. If this occurs the stone is likely to become very large and may weigh an ounce or more. In other cases the calculi may be very small, perhaps not larger than a grain of sand. One observer claims to have found nearly eight thousand of these small particles. The commonest appearance is that of a number of dark concretions, varying from the size of a small pea to that of a chestnut, and sometimes resembling a chestnut in appearance. From the rubbing together of their surfaces they produce polished facets of different size, depending upon the size and shape of the concretion against which they have rubbed. The appearance of a transverse section of a stone which has been cut may show the light cholesterin formation on the inside, with the dark pigmented or earthy formation on the outside. It will show concentric layers which represent the gradual deposit of the various substances of which the stone is formed. When a number of stones are present it will be found that the smaller ones may have slipped into the ducts while the larger ones occupy the gall bladder.
The presence of these stones induce changes more or less chronic in character. Inflammation is the most common result. The mucous membranes are all thickened and the ducts may be sacculated, dilated or stretched. Occasionally ulceration of the bladder walls takes place and the stone may escape into the peritoneal cavity, or fistulous tracts may be established between the gall bladder and other organs, through which small calculi may pass. From infection, suppuration will follow naturally, and pyemia, or empyemia may result. These changes may induce atrophy of the gall bladder in rare cases, or the walls of the bladder may become coated with calcareous matter, or its tissues may be filled with calcareous deposits, inducing a condition of calcification.
Symptomatology:—While hepatic colic, characterized by acute agonizing pain, is supposed to be a constant attendant of the passage of gall stone, it must be borne in mind that these stones may be present in the gall bladder for a long period without setting up any irritation or inflammation. It sometimes happens that there is sufficient dilatation of the ducts to permit of the passage of small stones and at times of stones of considerable size without pain, or with but little discomfort. Many observers have found concretions of all sizes in the feces, which had undoubtedly formed in the gall bladder and were passed without pain. Anders claims to have found one as large as an English walnut. On the other hand inflammation alone of the gall bladder, when no stone is present, may induce pain as severe as that of the passage of gall stones.
When the irritation produces an inflammation there may be fever, with circumscribed soreness, and sensation of weight and fulness, without pain. This may precede an attack of pain because of the fact that during the inflammatory process a calculus has slipped into the duct and is forcing its passage into the duodenum.
There are many cases of gall stone in which there are no symptoms whatever, until a sudden sharp intensely severe pain occurs about two and a half or three inches to the right of the median line of the abdomen, under the edge of the ribs. This radiates backward to the shoulderblade, or into the epigastrium, and is occasionally described as spreading over the entire abdomen. In other cases it has been so positively and persistently referred to the region of the stomach alone as to completely mislead in the diagnosis. While these facts are true in many cases, occasionally the pain is mild at the beginning, and is attributed to simple indigestion, but increases in spite of simple measures for its relief, until it becomes very severe.
The pain produces a shock to the nervous system. There is vomiting, dizziness, sometimes there is syncope and profuse perspiration, intense anxiety and pallor. The patient groans or screams with pain, flexes the thighs upon the abdomen, throws himself across a chair to compress the abdomen, or rolls upon the floor to obtain relief from the terrible paroxysms. This pain may last from two or three hours to two days, the pulse at first becomes slow and feeble and easily compressible; there are chills and the temperature will rise to perhaps 103° or 104° F. If the pain continues uninterruptedly and depression follows, the pulse will become small, feeble, rapid, and later irregular.
The pain is not always continuous in its extreme severity, but will remit at times, giving the patient considerable rest. The pain may be at its height for some time, when suddenly the patient will express relief, will fall back thoroughly exhausted and the pain has gone, the stone having escaped into the intestine. There may be every evidence of severe nervous shock in extreme cases, with threatened collapse, but more commonly after a short period of rest the patient recuperates rapidly and regains his usual health. In yet other cases the period of complete relief may last from half an hour to two hours, when the pain will recur with the severity of the former attack, from another calculus having entered the duct. This will induce conditions similar to those induced by the first one, or the conditions may be more or less severe than those of the first. There have been instances where one stone would follow another, with extreme pain with each one, for a number of days.
When the pain has continued from six to eight hours jaundice may appear, although it is not a constant symptom. In some cases it is delayed for twenty-four or thirty-six hours. The jaundice will occur directly if the calculus is in the hepatic duct. If the stone is in the cystic duct the inflammation may convey itself to the hepatic duct and induce thickening of the mucous membranes of the duct and temporary occlusion and consequent jaundice. Pressure also upon the hepatic duct will result in jaundice. This condition therefore, if present, is of much importance in diagnosis, but its absence does not prove the absence of gall stones. The occlusion of the duct by the stone results in a temporary enlargement of the liver. It will be distinctly outlined at some distance below the border of the ribs and will be found to be tender, sometimes exquisitely so. The spleen may be also enlarged. Bile will be found in the urine, which soon becomes albuminous. It is not uncommon that hematuria will occur. In cases where the pain is not distinctly located, it may be mistaken for a case of renal colic. As a result of this serious condition, there may be infection sufficient to induce suppurative cholecystitis, or dropsy, or if the common duct is obstructed, there may be persistent jaundice, with a cessation of pain which may not recur, or dropsy of the gall duct may follow.
If perforation occurs there will probably be a fatal peritonitis. A simpler form of localized peritonitis has resulted from the inflammation extending through the contiguous structures and involving the peritoneum; or the stone with bile and pus may escape into the pleural sac, inducing fatal purulent pleuritis; or the lung structure may become infected.
Diagnosis:—The diagnosis of the passage of gall stones would seem to be simple when the severe pain is so characteristic, but it must be borne in mind that severe pain occurs from gastric ulcer, from intestinal disorder, renal colic, diaphragmatic pleurisy, or from appendicitis, and from the gastric crises, of ataxia, which are most difficult to distinguish from the hepatic pain. That which occurs from gastric ulcer follows the ingestion of food and there is apt to be hematemesis. With renal colic suppression of urine may result. In pleurisy a local examination, with auscultation will reveal the condition; in appendicitis the local symptoms are very pronounced, and in ataxia the nervous symptoms are sufficiently distinct.
Hyperchlorhydria is depended upon often to distinguish between gall stone and stomach disorder, because that condition is present in gastric ulcer and in pyloric obstruction, and is apt to be absent during the passage of the gall stone. It is found present, however, in a number of cases after the stone has passed. A positive confirmation of the diagnosis is the finding of the concretions in the feces.
Prognosis:—No anxiety need be expressed as to the relief of pain and ultimate favorable outcome of these cases of there are no complications and if there have been but few previous attacks. Where a condition favorable to the formation of the stones has existed for a long time and structural change has taken place in the gall bladder, and where constitutional impairment from repeated attacks is more or less marked, the prognosis is less favorable. The severe pain may induce cerebral hemorrhage, or nervous shock, followed by serious sequelae, or there may be infection with empyema, or perforation, or other serious complications may make it necessary to give a guarded prognosis.
Treatment:—The immediate demand in the treatment is the relief from the agonizing pain. This must be accomplished at once, and is usually done by the administration of one-fourth of a grain of morphin, which may be repeated in half an hour in the severer cases. If relief docs not follow the first administration, this may be accompanied with atropin or nitroglycerin. In other cases it may be wise to administer chloroform at the first, and thus by producing extreme relaxation not only control the pain but permit the rapid passage of the stone before congestion and thickening of the mucous membrane occurs. It is only in very mild cases that hot baths or hot applications or local measures will give much relief, and the relief so obtained is usually transient. A dram of specific dioscorea villosa in a teacupful of hot water may be administered every fifteen or twenty minutes. If three doses do not give relief the remedy may be abandoned, as relief from this agent is prompt and efficient if it exercises any influence at all. The use of lobelia as a relaxing agent and the application of libradol in simple cases may be sufficient without the use of the more active measures.
It is in extreme pain of this character, where chloroform may be demanded, and where general relaxation is desirable, that the recently advised compound of hyoscin, morphin, and cactin, hypodermically, will probably prove of service.
When the pain is relieved, hot compresses may be applied over the liver to prevent the further development of local inflammation, and to favor an abatement of the symptoms and promote resolution. The patient should be mildly stimulated, the stomach soothed, and a small quantity of nutriment administered. The condition of the patient must then be studied carefully and remedies advised to change the conditions in the liver, in the gall bladder, or in the system at large, so that other stones will not form. When the presence of other stones in the gall bladder is determined it has been authorized practice for many years to administer large quantities of sweet oil and simple alkaline laxatives to promote the removal of such of these calculi as may readily pass through the ducts. I believe that much benefit has been obtained from the administration of from four to six ounces of pure olive oil two or three times a day. With the persistent use of sodium phosphate or small doses of the magnesium sulphate, there may be a better liquefaction of the bile. Two other excellent remedies to overcome local congestion, to relieve catarrhal inflammation and restore a normal condition of the mucous membranes, are hydrastis canadensis and ammonium chlorid. The former may be given in ten grain doses three times daily, combined with from five to eight grains of the latter. Where the catarrhal condition results in jaundice, with more or less chronic congestion of the liver, a course of treatment should be laid out, which should consist of either chionanthus, leptandrin, iris or chelidonium. The most of our writers speak highly of podophyllum in these cases, but I have failed to obtain satisfactory results from its action.
These patients should have a carefully selected diet; fat producing foods and pastries should be excluded, and skimmed milk may be drunk freely. Buttermilk is also excellent, and a small quantity of eggs, lean meat, always fresh, as cured meats should be excluded entirely, and vegetables and fruits in season may be allowed. Active physical exercise out of doors is advised by all clinicians. This may consist of walking, bicycle riding, golf playing or horseback riding.
If a tendency to constipation persists, the remedies above named, with Rochelle salts and an occasional dose of cascara, or cascara systematically prescribed, with saline laxatives, or with mildly laxative mineral waters, may be advised.
After an attack, if it is evident that stones which are too large to pass through the duct are yet present in the gall bladder, an operation must be performed. If an immediate attack of pain is not anticipated the patient should be restored as nearly as possible to a normal condition before the operation. If jaundice persists and there are recurring attacks of pain, with no tendency to full recovery, the best possible hour should be selected, and the operation should be no longer delayed, as repeated severe attacks of colic, with persistent jaundice, may follow, from the local influence of the calculi, which may result in perforation, or in conditions in which an operation would be contraindicated. As a justification for surgical interference, it may be stated that the mortality after operation has not exceeded three per cent in uncomplicated cases or five per cent in complicated cases.
