influential than errors of diet in causing concretions. The bile
accumulates in the gall-bladder, and the condition of repose favors the
occurrence of those changes which induce the separation and
crystallization of cholesterin. {1066} Obstacles to outflow of every
kind have the same effect. The largest calculus in my possession was
obtained from a case of cancer of the gall-bladder which compressed,
and finally closed, the cystic duct. Sedentary habits have the same
mechanical effect, but, as already pointed out, insufficient air and
exercise act by lessening oxidation. Corpulent persons indulging in
rich food and avoiding all physical exertion, those of such habits
confined to bed by illness or injury, the literary, the well-to-do,
self-indulgent, lazy, are usual subjects of this malady. Any condition
of things which causes a considerable retardation in the outflow of
bile will have a pathogenetic importance, especially if the causes of
chemical change, the lessened quantity of taurocholic and glycocholic
acid, and an increased quantity of cholesterin, coexist. Moral causes,
as fear, anxiety, chagrin, anger, etc., have seemed to exercise a
causative influence in some instances (Cyr).
[Footnote 165: _A Clinical Treatise on Disease of the Liver_, Syd. Soc.
ed., vol. ii. p. 511.]
To the causes of retardation of the bile-flow mentioned above must be
added catarrh of the bile-ducts. This acts in a twofold way--as an
obstruction; a plug of mucus forming the nucleus. It has already been
shown that fermentative changes may be set up by the mucus, which plays
the part of a ferment, an acid state of the bile resulting.
Situation of Gall-stones, and their Destiny.--The gall-bladder is, of
course, the chief site for these bodies, but biliary concretions and
masses of inspissated bile may be found at any point in the course of
the ducts. Single stones may be impacted at any point in the cystic,
hepatic, or common duct, or masses composed of numerous small calculi
may take the form of a duct and branches, making a branching calculus
of the shape and size of the mould in which it is cast. Such casts may
be hollow, thus permitting an outlet to the bile, or they may
completely close the tube, and a cyst form, the walls of which grow
thicker with connective-tissue deposits. Stones of very large size may
be thus enclosed, Frerichs having seen one the size of a hen's egg
formed about a plum-seed, which was the nucleus. In some rare instances
the major part of the larger tubes have been filled with inspissated
bile, through which the fluid bile could only be slowly filtered.
Calculi are not often found in the hepatic duct, since they can only
lodge there in descending from the smaller tubes, and hence are too
small to become wedged in. The usual site, as has been sufficiently
explained, is the gall-bladder. At the entrance to the cystic duct and
at the terminus of the common duct in the duodenum are the points where
migrating calculi are most apt to be arrested.
Spontaneous disintegration of gall-stones sometimes occurs. Cholesterin
being dissolved off of the corners and edges, the cohesion of the mass
is impaired and it falls apart in several fragments. By very slight
mechanical injury air-dried calculi will be broken up. In the
gall-bladder two factors are in operation to effect the disintegration
of the contained calculi: the movements of the body, by which the
corners and the borders are crumbled; the solvent action of the
alkaline bile on the cholesterin. When, however, these concretions are
made up of lime and pigment, their integrity can be impaired only by
the process of cleavage; no solvent action can take place.
Various changes occur in the ducts or in the gall-bladder in
consequence of the presence of these concretions. Whilst a catarrhal
state of the mucous {1067} membrane of the ducts is an element of much
importance in the process by which concretions are formed, on the other
hand the presence of these bodies excites catarrh, ulceration,
perforation, and, it may be, abscess of the liver. When concretions
form or are deposited in the ducts, they cause inflammatory reaction,
the walls yield, and the neighboring hepatic structures may also be
affected by contiguity. The dilatation of the tube is usually
cylindrical, much more rarely sacciform. The neighboring connective
tissue may undergo hyperplasia and a more or less extensive sclerosis
occur. More frequently the calculus ulcerates through, and an abscess
is produced which will take the usual course of that malady. Very
rarely a calculus is found enclosed in a separate sac and surrounded by
healthy hepatic tissue (Roller).[166]
[Footnote 166: _Berliner klin. Wochensch._, No. 42, 1879; _ibid._, Nos.
16, 17, and 19 for 1877, Fargstein.]
As the gall-bladder is the usual place for the formation and storage of
gall-stones, the changes in connection with this organ are the most
important. The calculi may be so numerous or so large as to distend the
gall-bladder and cause it to project from under the inferior border of
the liver, so as to be felt by palpation of the abdominal wall. The
stones may be few in number and float in healthy bile, or they may fill
the bladder to the exclusion of fluid, the cystic duct being closed
permanently; or there may be, with one or more concretions, a fluid
composed of mucus, muco-pus, serum, and bilious matter. The mucous
membrane may be in a normal state, but this is rare; usually it is
affected by the catarrhal process, and atrophic degeneration has taken
place to a less or greater extent; the rugæ are obliterated, the
muscular layer hypertrophied. When attacks of hepatic colic have
occurred, more or less inflammation of the peritoneal layer of the
gall-bladder and cystic duct is lighted up, and organized exudations
form, changing the shape and position of the organs concerned. It is
usual in old cases of hepatic colic to find the gall-bladder bound down
by strong adhesions, the cavity much contracted or even obliterated,
the cystic duct closed, and the neighboring portion of the liver the
seat of sclerosis. Such inflammatory exudations about the gall-bladder
may become the seat of malignant disease--of scirrhus. Several examples
of this have been reported, and one has occurred in my own practice.
The contact of a gall-stone, especially of a polyangular stone, may
cause ulceration of the mucous membrane. This is the more apt to occur
if the muscular layer of the gall-bladder is hypertrophied, especially
if certain fasciculi are thickened and overacting, leaving intervening
parts weak and yielding to the pressure of the stone forced in by the
spasmodically contracting muscles. Finally yielding, the stone and
other contents of the gall-bladder escape into the cavity of the
abdomen. Adhesions to neighboring parts may prevent rupture. Such
adhesions are contracted with the colon, the duodenum, the stomach, and
other organs. In some rare instances the closed gall-bladder has
undergone a gradual process of calcification, the mucous membrane
losing its proper structure, the muscular layer degenerating, and a
slow deposit of lime salts taking place, the ultimate result being that
the biliary concretions are enclosed in a permanent shell.
As above indicated, biliary concretions may remain where deposited for
an indefinite period. Very often they migrate from the point of
formation, the gall-bladder, into the duodenum, producing
characteristic {1068} symptoms called hepatic colic. As the size of the
ducts increases from above downward, obviously but little vis a tergo
is needed to propel the concretions onward. The chief agency in the
migration of these bodies is the discharge of bile. Common observation
shows that the symptoms of hepatic colic usually declare themselves in
two or three hours after a meal--at that time when the presence of the
chyme in the duodenum solicits the flow of bile. The gall-bladder
contracts on its contents with an energy in direct ratio to the amount
of bile present, and with the gush of fluid the concretion is whirled
into the duct. Once there, the cystic duct being unprovided with
muscular fibres, the onward progress of the stone must depend on the
flow of bile; and, as the canal is devious, this may not always carry
the concretion into the common duct. Just behind the neck of the
gall-bladder the duct makes an angle somewhat abrupt, and here also its
folds project into the canal, so that at this point the stone is apt to
lodge; but much depends on the size and shape of the calculus. If it
pass through the cystic duct, the inflammation resulting may close the
canal, several instances of which have fallen under my observation. The
next point where stoppage of the migrating calculus may, and frequently
does, occur is the orifice of the common duct in the duodenum. This
orifice has a funnel shape, the smaller extremity toward the intestine,
the object of this being to prevent the entrance into the duct of
foreign bodies from the intestine. A diverticulum is thereby made
(Vater's) in which a concretion may lodge, partly or wholly preventing
the escape of bile into the bowel. The various forces concerned in the
propulsion of the concretion onward from the common duct into the
intestine are the discharges of bile, the contraction of the few
muscular fibres in the walls of the duct, the respiratory movements,
especially forced expiration, coughing, sneezing, vomiting,
defecation--in fact, all of those acts in which the abdominal muscles,
the diaphragm, and the sphincters are simultaneously brought into
strong contraction. The symptoms produced by the migration and stoppage
of a concretion will vary according to the size and shape of the stone,
and the consequent diminution in the amount of bile discharged or its
complete arrest. In other words, the stone may be firmly wedged in,
completely closing the canal against the passage of bile, or it may lie
loosely in the diverticulum Vateri, acting as a sort of ball valve, now
permitting a gush of bile, and now stopping the passage-way more or
less tightly.
The migration of calculi may take place by ulcerating through into
neighboring hollow organs. Usually the first step consists in stoppage
of the bile. To the accumulating bile mucus is added, and the
gall-bladder or the duct--usually the common or cystic duct--dilates,
often to a considerable extent, and, adhesions forming, discharge
ultimately takes place through some neighboring hollow organ. The
routes pursued by such fistulous communications are various. The organs
most frequently penetrated are the stomach, duodenum, and colon, less
often the urinary passages, and very rarely the portal vein. Numerous
examples of external discharge of calculi have been reported. The most
usual, as it is the most direct, is the fistulous connection of the
gall-bladder or common duct with the duodenum. Solitary stones of
immense size have been thus discharged. Murchison[167] gives references
to many interesting {1069} examples, and the various volumes of
_Transactions of the Pathological Society_ are rich in illustrative
cases. The symptoms produced by the migration of calculi by the natural
route and by ulceration into other organs will be hereafter considered.
[Footnote 167: _Clinical Lectures on the Diseases of the Liver_, 2d
ed., p. 487 _et seq._]
SYMPTOMS DUE TO THE PRESENCE OF GALL-STONES AT THEIR ORIGINAL
SITE.--Very large calculi or numerous small ones may be present in the
biliary passages without causing any recognizable symptoms. The
migration of these bodies by the natural channel and by ulceration into
the duodenum may also be accomplished without any local or systemic
disturbance.[168] That the retention of calculi may not induce any
characteristic reaction by which they may be recognized is probably due
to the fact that the gall-bladder, in which they chiefly form,
possesses but slight sensibility, and as it is in a constantly changing
state of distension or emptiness according to the amount of bile
present, it is obvious that a foreign body made up of the biliary
constituents, and having nearly the same specific gravity as the bile,
is not likely to cause any uneasiness or recognizable functional
disturbances. Furthermore, the slowness with which biliary concretions
form enables the organ to accommodate itself to the new conditions. The
lack of sensibility which is a feature of the gall-bladder, and which I
have had the opportunity to ascertain by actual puncture in an
individual not anæsthetized, is in some instances supported by a
general state of lowered acuteness of perception. There are great
differences in respect to readiness of appreciation and promptness of
response to all kinds of excitation in different individuals. To what
cause soever we may ascribe the lack of sensibility, the fact remains
that in not a few cases of gall-stones in the gall-bladder there are no
symptoms to indicate their presence. On the other hand, there are some
disturbances that have a certain significance.
[Footnote 168: Amongst the numerous examples of this kind to be found
recorded may be mentioned the case reported by M. L. Garnier, Agrégé à
la Faculté de Médecine de Nancy (_Archives de Physiologie normale et
pathologique_, No. 6, 1884, p. 176): An hepatic calculus, weighing 24.5
grammes, was discharged without any symptoms or even consciousness on
the part of the patient, a man of sixty years. He had had colic and
jaundice, but these subsided entirely, and there was no further
disturbance. As has happened in so many instances, this stone must have
ulcerated through into the bowel without causing any recognizable
symptoms.]
The subjective signs are uneasiness--a deep-seated sensation of
soreness--felt in the right hypochondrium, increased by taking a full
inspiration and by decubitus on the left side. Pain or soreness,
sometimes an acute pain, is experienced under the scapula near the
angle, at or about the acromion process, and sometimes at the nape of
the neck. In one case under my observation within the past year a
patient who had had several attacks of hepatic colic, the usual
polyangular stones having been recovered, had from time to time severe
pain over the right side of the neck, shoulder, and scapula,
accompanied by a severe herpes zoster in the district affected by the
pain. This is of course an extreme example, but it is very suggestive
of the relation which may exist between hepatic disturbances and
shingles. Attacks of gastric pain coming on some time after food, and
not soon after, as is the case in true gastralgia, are usual in the
early stage of the disease--are constant, according to Cyr,[169] who
quotes approvingly an observation of Leared on this point. Migraine
{1070} or sick headache and vertigo occur in many cases, but it may
well be doubted whether these symptoms are not due to the accompanying
gastro-duodenal catarrh, which is a nearly constant symptom. Acidity,
flatulence, epigastric oppression, a bitter taste, a muddy rather
bilious complexion, and constipation are symptoms belonging to catarrh
of the gastro-duodenal mucous membrane. Most of these symptoms are
rather indefinite. Some additional information may be supplied by
palpation. 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. There may be also some
tenderness on pressure along the inferior margin of the ribs,
especially in the region of the gall-bladder.
[Footnote 169: _Traité de l'Affection calculeuse du Foie_, p. 71.]
SYMPTOMS DUE TO THE MIGRATION OF GALL-STONES BY THE NATURAL
CHANNELS.--A calculus passing into the cystic duct from the
gall-bladder causes the disturbance known as hepatic colic or bilious
colic, because of the jaundice which accompanies the major part of
these seizures. But jaundice is not a necessary element in these cases;
it is not until the concretion reaches the common duct that the passage
of bile into the intestine is interfered with. The gall-bladder has a
function rather conservative than essential, for its duct may be
permanently closed without apparently affecting the health.
The time when an attack of hepatic colic is most likely to occur would
seem to be determined by the flow of bile; for this, as has been
stated, is the chief factor in moving calculi along the ducts. As, no
doubt, the presence of the chyme in the duodenum is the stimulus for
the production of bile and also for the contractions of the
gall-bladder, it follows that a few hours after meals is the time when
the attacks of hepatic colic would a priori be expected. This is in
accord with experience, but there are exceptions. In one of the most
formidable cases with which the writer has had to deal--the diagnosis
confirmed by the recovery of the calculi--the most severe attacks
occurred in the early morning. According to Harley,[170] colic from the
passage of inspissated bile occurs when the stomach and duodenum are
most nearly empty--from ten at night until ten in the morning--and this
he relies on as a means of diagnosis, but the exceptions are too
numerous to assign much importance to this circumstance.
[Footnote 170: _On Diseases of the Liver_, p. 354.]
The onset of pain is usually sudden, but it may develop slowly from a
vague uneasiness in the region of the gall-bladder; or after some pain
and soreness at this point, accompanied by nausea, even vomiting, the
paroxysm will begin with very acute pain. The situation of the pain is
by no means constant, and usually varies in position in the same case.
The point of maximum intensity is near the ensiform cartilage, outward
and downward two or three inches, about the point of junction of the
cystic and common duct. From or about this region the pain radiates
through the epigastrium, the right hypochondrium, upward into the
chest, {1071} backward under the scapula, and downward and inward
toward the umbilicus. In some instances under my observation the most
acute suffering was located in the right iliac region, in others in the
lumbar region, and in still others in the epigastrium. The position of
the pain may be such as to draw attention from the liver, and thus
greatly confuse the diagnosis. In a well-defined attack the pain is
intense, shooting, and boring, irregularly paroxysmal; the patient
writhes in agony, screams and groans, rolls from side to side, or walks
partly bent, holding the part with a gentle pressure or rubbing with an
agonized tension of feeling. Meanwhile the countenance is expressive of
the intensest suffering, is pallid and drawn, and the body is covered
with a cold sweat. Nausea presently supervenes, and with the efforts to
vomit a keen thrust of pain and a sense of cramp dart through the
epigastrium and side. Very considerable depression of the vital powers
occurs; the pulse becomes small, feeble, and slow, or very rapid and
feeble. The patient may pass into a condition of collapse, and, indeed,
the pain of hepatic colic may cause death by sudden arrest of the
heart's action. The cases which prove fatal in this way are doubtless
examples of fatty heart, the degeneration of the cardiac muscle being a
result of the action of the same factors as those which cause
gall-stones to form, if the relation of general steatosis to these
bodies which I have set forth prove to be true. The pain is not
continuously so violent as above expressed: it remits from time to
time, and seems about to cease altogether when a sudden access of
anguish is experienced and the former suffering is renewed, and, it may
be, more savagely than before. The pain of an attack of hepatic colic
has no fixed duration. It will depend on the size of the calculus, on
the point where impacted, and on the impressionability of the subject.
The severity of the seizures varies within very wide limits. The attack
may consist in a transient colic-like pain, in a mere sense of
soreness, in epigastric uneasiness with nausea, or it may be an agony
sufficient to cause profound depression of the powers of life--to
destroy life, indeed. The usual attack of hepatic colic is one in which
severe suffering is experienced until relief is obtained by the
exhibition of anodynes. Under these circumstances the subsidence of the
pain may be rather gradual or it may be sudden: in the former case, as
the effects of the anodyne are produced, we may suppose that the spasm
subsides and the stone moves onward, at last dropping into the
intestine: an enchanting sense of relief is at once experienced. Very
serious nervous disturbances may accompany the pain. Paroxysms of
hysteria may be excited in the hysterical; convulsions occur in those
having the predisposition to them from any cause, and in the epileptic.
The onset of a severe seizure is announced by chilliness, sometimes by
a severe chill. Now and then the paroxysms commence with the chill, and
the pain follows. It occasionally happens that the attacks in respect
to the order in which the symptoms occur, and in their regularity as to
time, behave like an ordinary ague. In fact, there appear to be two
modes or manifestations of the attacks of hepatic colic in malarious
localities: those in which the phenomena are merely an outcome of the
passage of the calculi; those in which an attack of intermittent fever
is excited by the pain and disturbance of hepatic colic. To the first
Charcot[171] {1072} has applied the phrase fièvre intermittente
hépatique. It is supposed to correspond pathogenetically to urethral
fever produced by the passage of a catheter. On the other hand, the
second form of intermittent can occur only under the conditions
producing ague. A calculus passing in a subject affected with chronic
malarial poisoning, the latent malarial influence is aroused into full
activity, and the resulting seizure is compounded of the two factors.
The truly malarial form of calculus fever differs from the traumatic in
its regular periodicity and the methodical sequence of the attacks,
which occur in the order of an intermittent quotidian or tertian.
During the attacks of hepatic colic, when protracted and severe, a
sense of chilliness or distinct chills occur, sometimes with the
regularity of an intermittent; but these differ from the seizures which
the chill inaugurates at distinct times, the intervening period being
free from disturbance.
[Footnote 171: _Leçons sur la Maladies du Foie_, p. 178.]
The fever which accompanies some severe paroxysms of hepatic colic has
a distinctly intermittent character, hence the name applied to it by
Charcot. There are two forms of this calculus fever as it occurs in
malarious localities: one intermittent, coming on during a protracted
case, and immediately connected with and dependent on the passage of
the stone; the other a regular intermittent quotidian or tertian, which
determines and accompanies the paroxysm of colic. A case occurring
under my observation very recently, in which these phenomena were
exhibited and the calculi recovered, proves the existence of such a
form of the malady. In this case with the onset of the pain a severe
chill occurred; then the fever rose, followed by the sweat, during
which the pain ceased, but much soreness and tenderness about the
region of the gall-bladder, and jaundice, followed in the usual way. At
the so-called septenary periods also attacks come on in accordance with
the usual laws of recurrence of malarial fevers.
Not all cases are accompanied by fever. In many instances, probably a
majority, the pulse is not accelerated, rather slowed, and the
temperature does not rise above normal. The inflammation which follows
an attack of hepatic colic will be accompanied by some elevation of the
body-heat, and fever will occur when ulceration of the duct and
perforation cause a local peritonitis; but these conditions are quite
apart from those which obtain in the migration of calculi by the
natural channel.