=Gall-stones= are concretions that originate in the gall-bladder
and occasionally in the hepatic ducts. “The primary formation of
gall-stones is itself largely dependent upon =stagnation= of bile,
such as may arise in the gall-bladder if an intermittent or incomplete
closure of the cystic duct be brought about by such things as
tight lacing, pregnancy, or even unequal sagging of the abdominal
viscera.”—MacCallum. The stone is largely composed of cholesterin, and
may form without any inflammation of the gall-bladder, owing probably
to the stagnation affecting the bile salts so that the cholesterin is
precipitated instead of being held in solution.
More often there is inflammation of the wall of the gall-bladder due
to micro-organisms. This causes an exudate from which is derived the
calcium. The calcium with bilirubin is deposited in layers on the stone
which give it the various colors of yellow, brown or green.
A rare type is one formed in the hepatic ducts, which is soft, green,
and composed of calcium bilirubin concretions.
The stones “contain a great deal of organic material derived from
desquamated epithelial cells and coagulated albuminous matter, as well
as pigment.” The colon bacilli, staphylococci, streptococci, typhoid
bacilli, and pneumococci are the bacteria most frequently found. A
=cholecystitis= may be a predisposing factor or it may be secondary to
the concretion.
=Osteopathic Etiology= and =Pathology=.—This is a disease of middle
life and is more frequently found in women. Sedentary habits and
constipation combined with overeating, are other important factors.
It is found in stout subjects who are particularly fond of starchy
and saccharine food. Catarrhal jaundice is a predisposing factor.
Depressing mental influences may predispose. The thicker the bile the
more likely it is to deposit. Dr. Still’s theory is that lesions of the
ribs on the left side from the sixth to the tenth dorsal are factors
in the formation of the stones as they interfere with pancreatic
secretions. No matter how it comes about, the fact is that in all cases
of gall-stones the osteopath finds lesions to the eighth, ninth and
tenth ribs on the left side, as well as lesions from the fifth or sixth
to the tenth dorsal, deranging innervation to the liver and bile ducts.
It is possible that lesions over the spleen probably interfere with the
activities of the spleen and thus in some manner this organ does not
properly elaborate the blood before it passes to the liver. Sagging
of the duodenum may, through tension on the duodeno-hepatic ligament,
interfere with the flow of bile. This would cause derangement of the
nervous reciprocal relationship between opening at duodenal orifice and
gall-bladder. In carcinoma of the liver and stomach, gall-stones are
said to be frequent.
The stone itself is a brownish object, nearly spherical, faceted and
in some instances polygonal in shape, varying in size from a pea to a
hen’s egg.
The stones are found anywhere in the biliary tract from the duodenal
orifice to the ramification of the bile vessels. Usually there is more
or less of an accumulation in the gall-bladder. At any point the stone
may produce ulceration and suppuration. Perforation may occur into the
peritoneal cavity or adjacent organs.
=Symptoms.=—Gall-stones may be in the gall-bladder for years without
giving rise to any symptoms. Their presence is made known only by their
expulsion from the gall-bladder. If they lodge in the duct in transit
from the gall-bladder to the duodenum =biliary colic= is produced,
which is the characteristic symptom of an impacted gall-stone. Small
stones may pass into the intestine without producing symptoms. The
pain is very sudden, piercing and excruciating in the region of the
gall-bladder, when a stone attempts to pass. The pain radiates through
the abdomen, right chest and shoulder, and the patient writhes in agony
and occasionally faints. Downing[90] emphasizes the point that when a
patient comes in with a history of repeated attacks of biliary colic
and no stone found in the stools one should at once suspect that one of
considerable size obstructs the common duct.
There is always tenderness in the biliary region with more or less
contraction of the abdominal muscles. Nausea, vomiting and sweating
are usually present, followed by a weak pulse, cool skin and pale
and anxious face. Fever is soon present and a chill is common. The
paroxysms continue as long as the stone remains lodged, which may be
from an hour to several days. There are remissions of pain, entire
relief being given as soon as the stone reaches the duodenum. Jaundice
usually follows a prolonged attack. The liver is sometimes enlarged.
The spleen is enlarged. Should the stone become impacted, ulcerative
perforation, with consequent peritonitis and shock, follows.
=Diagnosis.=—The diagnosis is conclusive when the gall-stones are found
in the stools or when they can be felt in the gall-bladder. All the
above symptoms are characteristic. If a patient complains of severe
pain radiating from the hepatic region, and nausea and vomiting are
present, subsiding suddenly with a slight jaundice, the disease should
hardly be mistaken.
Tenderness over the gall-bladder frequently indicates infection or
gall-stones or both. Radiographic examination may be of aid.
=Nephritic colic= should never be confounded with hepatic colic
as in the former the pains start in the lumbar region and radiate
downward into the groin, the testicle and the inside of the thigh.
In =appendicitis=, jaundice and bile-stained urine are not found. A
=pseudo-biliary colic= is occasionally found in nervous individuals
especially when the eleventh and twelfth ribs (or ribs as high as the
seventh) on the right side are displaced downward.
=Prognosis.=—Is usually favorable. Ulceration, perforation, and
suppuration may prove fatal, although much depends upon surgical
interference.
=Treatment.=—During the attack of =biliary colic=, the osteopath should
usually be able to readily locate the position of the gall-stone in
its transit from the gall-bladder. He should usually proceed at once
to aid the stone in its downward passage by careful manipulation over
the duct. Still this treatment should be given with great caution,
for if there is suppuration or ulceration, perforation and resultant
peritonitis may occur.
Usually one will not have much difficulty in dislodging the stone
and relieving the sufferer in a few minutes. The recumbent position,
with the thighs flexed on the abdomen, is the position assumed for
treatment, and if the muscles in the hepatic region are very tense
and rigid, interfering with locating the gall-stone, an inhibitory
treatment to the posterior spinal nerves supplying the contracted
muscles will aid one materially. An inhibitory treatment of the nerves
of the biliary tract (the ninth and tenth dorsals), may be a helpful
measure in dilating the duct. Also, hot application over the affected
area and to the dorso-lumbar region will aid.
During remissions two or three treatments per week should be given
to correct the lesions at the eighth, ninth, tenth and eleventh
segments. Give particular attention to any enteroptosis that may be
found. Average cases should not require more than two or three months’
treatment. Hildreth, who has had many cases, is much opposed to
operation as his experience has been that where there is not complete
obstruction the correction of lesions will prevent further formation of
stones. While he finds the trouble ranges from the third to the eighth
dorsal, still, as a rule, it is between the fifth and sixth that best
results are obtained. Probably if the treatment is a rightly directed
one the stones already formed may be disintegrated. Willard[91] reports
393 cases.
Permanently impacted gall-stones require surgical treatment.
Prophylactic treatment, as a regulated diet, daily exercise and a
discontinuance of excesses, should be strongly urged. The patient
should not be allowed any fatty or saccharine food. Water freely taken
will be of aid.