462 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM.






The manifestations of the presence of gall-stones may be considered under
several headings :

1. Biliary colic is due to acute impaction resulting during the passage of
stones through the larger bile ducts. The passage of the calculus usually
gives rise to severe attacks of pain which are sudden in onset and referred to
the epigastrium or right h}q3ochondrium whence it may radiate to the right
shoulder or to any part of the abdomen. The pain is excruciating and lan-
cinating in character and may cause syncope. The liver may be enlarged,
tenderness is usually present and the gall-bladder may be palpable; there is
abdominal rigidity; nausea and vomiting occur. There are often chills; the
temperature rises to 102° to 103° F. (38.9° to 39.5° C.) or even higher. The
fever may be intermittent in t}^e but is more apt to assume this form in pro-
tracted obstruction due to chronic impaction of calculi (intermittent hepatic
fever). There may be circulatory depression with rapid and feeble pulse.

There is usually splenic enlargement and if the attack is prolonged,
jaundice is likely to appear, particularly if the stone becomes impacted in the
opening of the common duct. The paroxsym of colic varies in duration
from a few hours to a week or more; it may recur at intervals, the symptoms
ultimately disappearing with the passage of the calculus.

Rupture may take place at the site of the obstruction with death from
peritonitis as a result; convulsions have been observed.

The diagnosis is seldom difficult; the site of the pain is characteristic and
its occurrence with tenderness over the liver, a chill and jaundice leaves
hardly room for doubt. The history is often of marked assistance. Renal
colic is accompanied by pain radiating downward to the groin or testicle and
by bloody urine which often contains pus cells. Appendicitis, while possibly
associated with pains similar to those of hepatic colic, is not attended with
jaundice. The pseudo-biliary colic which may occur in women may be differ-
entiated by the absence of jaundice and the presence of nervous symptoms
of various kinds. Finding calculi in the feecal discharges is confirmatory
of the diagnosis of gall-stone colic. A search for these should always be made
in suspicious instances during the three or four days following an attack. The
stools should be washed upon a fine seive until aU soluble matter has been
flushed through.

The prognosis as to recovery from the paroxysm is favorable, death from
syncope, perforation or convulsions being a rare occurrence.

2. Chronic Impacted Gall-stone: During the passage of a calculus through
the ducts toward the duodenum impaction not infrequently takes place.
The impaction may occur,

a. . In the Cystic Duct.

Symptoms. These may resemble in greater or less degree those of acute im-
paction with added dilatation of the gaU-bladder {hydrops vesiccs fellece). The



CHOLELITHIASIS. 463

dilatation is the result of the accumulation of the exudation due to inflammation
of the lining mucous membrane plus the bile that was present when the
obstruction took place. The increase in the size of the gall-bladder may be
crreat and the condition has been mistaken for ovarian cyst. On opening the
gall-bladder the fluid contents is found to consist chiefly of mucus of alkaline
or neutral reaction. Jaundice may not be present and, while at times the dis-
tended gall-bladder may not be palpable, it may often be felt as a rounded or
<rourd-shaped fluctuating tumor projecting downward or to the left toward
the mid-line of the abdomen. If the abdominal wall is thin and relaxed
crepitus due to the presence of calculi may be demonstrated.

b. Impaction in the Common Bile Duct.

Symptoms. The obstruction may be due to one or several stones firmly
fixed in any portion of the duct or in the ampvflla of Vater. If a considerable
number of calculi is present these may fill the hepatic and cystic ducts as weU.
Dilatation of the gall-bladder to a sUght degree may be observed but is by
no means constant. Cholangitis is a usual sequence and may be either of
chronic catarrhal or of suppurative type.

In chronic catarrhal cholangitis due to permanent obstruction there is
marked and permanent jaundice, nausea and vomiting may be present and
the condition may be differentiated from obstruction due to neoplasm by the
history of previous colic, the pain, which may be intermittent, and the absence
of increase in the size of the gaU-bladder. A Hmpid mucoid fluid is usually
found in the distended ducts.

Naunyn mentions the following diagnostic signs of calculus in the common
duct: "(i) The continuous or occasional presence of bile in the faces; (2)
distinct variations in the intensity of the jaundice; (3) normal size or orfly
slight enlargement of the liver; (4) absence of distention of the gall-bladder;
(5) enlargement of the spleen; (6) absence of ascites; (7) presence of febrile
disturbance, and (8) duration of the jaundice for more than a year."

Incomplete obstruction with infective cholangitis is usually evidenced by
rather typical symptoms but the causative condition, which may be either
a number of stones in the common duct, one of which is movable, or the so-
caUed ball-valve calculus which is most often found in the ampulla of Vater,
but sometimes in the common duct; this may exist without causing any
suspicion that gall-stones are present. The ball-valve calculus evidences
its presence by a rather characteristic train of symptoms which consists of a
febrile movement occurring in malaria-like paroxysms and associated with
rigors and sweats (intermittent hepatic fever) and persistent jaundice of var}'ing
degree but which is intensified after each febrile paroxysm, this last often
being accompanied by the manifestations of gastric irritation and hepatic
pain. Such manifestations may appear from time to time during a period
of several years without the incidence of suppurative inflammation. The



464 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONAEUM.

rises in temperature are probably due to some mild infection, possibly the
result of the presence of the bacillus coli communis although they have also
been explained upon the ground of irritation. In the diagnosis of common
duct obstruction it is to be remembered that this condition, when due to stone,
does not give rise to dilatation of the gall-bladder. This rule (Courvois-
ier's law) is valid in about 90 percent, of cases but the following exceptions
have been mentioned by Moynihan: " (i) When there is a stone or a stric-
ture in the cystic duct causing hydrops or empyaema, together with the acute
impaction of a stone in the common duct; (2) where there is a stone in the
cystic duct pressing upon the common duct; (3) when there is distention
of the gall-bladder by an acute inflammatory process, with obstruction of
the common duct by stone; (4) where there is chronic induration of the head
of the pancreas, with a stone in the common duct; (5) where there is
malignant disease of the common duct at any part of its course, or cancer
of the head of the pancreas, and a chronic sclerosing cholecystitis."

Suppurative cholangitis is evidenced by a fever of more distinctly septic
character than that just described ; the remissions are less distinct and shorter and
with the paroxysms there is no augmentation of the jaundice. There are hepatic
tenderness and enlargement and the suppiurative process often extends into the
ducts in the liver, causing abscess, as well as into the gall-bladder. The evolution
of the condition is shorter than that of infective cholangitis and death is the
usual termination. Post mortem, the mucous lining of the ducts is found thick-
ened and perhaps ulcerated; abscess may be present in the liver substance and
pus may distend the gall-bladder. Rupture of this viscus has been observed.

Remote effects of impaction of gaU-stones: Biliary fistulae are not infre-
quently observed. The fistulous opening most commonly met is that in
which external perforation through the skin has taken place; the most usual
situations are the right hypochondriac and the umbilical regions. Gall-stones
may be discharged and recovery, even without operation, may follow. Ulcera-
tive perforation may take place into the peritonaeal cavity with localized
abscess formation, general peritonitis or retroperitonaeal perforation. Com-
munications between the bile ducts themselves, the gall-bladder or the intes-
tine are common, the usual exit of large calciili being through a colonic per-
foration. Fistulous openings into the portal vein and stomach are rare.
Perforations into the pleura, lungs and urinary passages have been observed.

Septic cholecystitis, empyaema of the gall-bladder, may follow the suppura-
tive cholangitis of impacted stone. Calcification of the mucous lining or
of the entire wall of the bladder may supervene upon purulent inflammations
and atrophy of the viscus may take place after the excessive dilation of hydrops.
Suppurative pylephlebitis or hepatic abscess may result from purulent cholan-
gitis. Intestinal obstruction due to biliary calculus, the stoppage being most
usually observed at some point in the ileum, is not very uncommon.



CHOLELITHIASIS. 465

Of the other results of gall-stone disease the following should be mentioned:

1. Diabetes mellitus. Gall-stone impacted in the lower end of the common
duct or in the diverticulum of Vater may lead to infection, as previously stated,
chronic interstitial pancreatitis and destruction of the islands of Langerhans.

2. Glycosviria from the same course of events with interference with the func-
tions of the islands of Langerhans. 3. Chronic interstitial pancreatitis with
amylaceous or lipatic indigestion and malnutrition. 4. Gall-stone impacted
in the duodenum allowing penetration of bile into the duct of Wirsung with
hasmorrhagic pancreatitis.

The diagnosis of the condition of intermittent hepatic fever is usually
not difl&cult, its peculiar febrile movement with rigors, sweats and jaundice
being characteristic. Cancer of the gall-bladder is not associated with a
rise in temperature, is characterized by greater tenderness and more rapid
emaciation. The use of the aspirating needle is quite justifiable as a means
of differentiation.

In making a diagnosis of gall-stone disease the frequency of biliary calculi
in elderly persons as a result of senile atrophy of the smooth muscle tissue in
the walls of the gall ducts and bladder, should not be forgotten.

The Rontgen ray is much less efiicient as an aid in the diagnosis of hepatic
calculi than in that of renal or ureteral stone. Plates showing gall-stones
have been obtained but the chance of successful demonstration of a calculus
is smaU, the material of which most of these are formed offering little obstruction
to the ray. Cholesterin stones appear to be transparent to the X-light; those
containing calcium carbonate are much more likely to throw a shadow on the
plate. The proper position in which to place the patient who is being radio-
graphed for gall-stone is face downward upon the plate, the body being bent
backward by placing supports under the thorax and pelvis, while the tube
is placed a little to the right of the median line opposite a point a little below
the level of the free border of the liver.

Treatment. Surgery has a distinct place in the treatment of gall-stones
but the treatment of gall-stone disease may with truth be said to be entirely
medical. Operative measures are adapted only to gall-stones of gall-bladder
origin and then only under conditions which demand mechanical relief.
Upon consideration of post mortem records it is seen that from 6 to 10 percent,
of all cadavers show the presence of biliary calculi and when it is shown that
not more than i person in 20 of those who harbor gall-stones becomes aware
of their presence as evidenced by symptoms, in many instances insufficient
to require operation, it is readily demonstrable that the field of surgery is
decidedly limited, although of great importance in selected cases. Keeping
these facts in mind, and remembering the distinction between gall-stone disease
and gall-stones, more will be expected of the internalist and fewer disappoint-
ments will be attributed to the failure of surgery.
30



466 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM.

The treatment of the microbic causes of biliary calculi is that of the re-
sponsible infection itself and the limitation of opportunities for entrance of
the infectious agent. The management of the congestive disorders referable
to the heart, lungs, etc., which predispose to the formation of gall-stones and
that of the mechanical conditions, such as pregnancy and visceral displace-
ments need not be dealt with here. The proper treatment of the foregoing
states will accomplish much in the prophylaxis of gall-stone disease.

Aside from the measures indicated in the relief of an acute attack of biliary
coSc the treatment should be based upon the general conditions mentioned
in the immediately preceding paragraph. The administration of olive oil
by the mouth for the acute paroxysm and for the other phases of the disease,
even in those cases in which it is tolerated in sufi&ciently large amounts and
for long periods of time, has utterly failed to produce even relief. Operative
procedures during an attack, theoretically so clearly indicated for an impend-
ing suppurative cholecystitis, have almost uniformly resulted in death so far
as the author's observation goes.

It has become apparent that the important feature of the treatment of gall-
stone disease is the regulation of congestions and inflammations in the portal
system and dependent organs, and in local antiseptics. The spa treatment
appeals to many. Success is based upon the fact that at the resort the patient's
habits of life are regulated, the diet is controlled and the use of the salines
diminishes congestions and inflammations in the portal area. Of these Neu-
enahr, Kissingen, Vichy, in Europe, Bedford, Sharon and Las Vegas in the
United States are preferred. Carlsbad has the advantages of many and
varied attractions but on account of these it is difficult to induce patients
to steadfastly and seriously attend to the business of getting well; because
of this fact, even though the waters of this resort are preferable to those of
many others, a sojourn at this spa is often of little benefit.

Within recent years it has become possible to obtain practically as good
results at home as at the water cures by means of the subjoined regime honestly
followed: i. Diet: This should be mixed, for vegetable food produces a
smaller amount of bile acids, and saccharine or fatty foods give rise to intes-
tinal fermentation. The meals should be limited in amount, taken at fre-
quent intervals to ensure constant flow of bile, with plenty of plain or feebly
mineralized water before each repast. Alcohol is prohibited. 2. Exercise,
especially in the open air, is important. 3. Cholagogues: With the excep-
tion of salicylic acid and certain salts, of bile itself and especially of salts of
the bile acids, it is doubtful if the drugs usually so designated are more than
temporarily effective. As for salicylic acid there is no doubt as to its chola-
gogue properties, that it is excreted in the bile and thus disinfects the bile
passages. No advantage is possessed by sodium salicylate given in con-
junction with sodium bicarbonate or sodium benzoate. Salicylic acid is pref-



CHOLELITHIASIS. 467

erable not only on account of its cholagogue properties but because it is a
biliary and intestinal disinfectant as well (which the salicylates are not)
and thus diminishes intestinal catarrh. The bile acids in intestinal putre-
faction are believed to be chemical antiseptics, physiological cholagogues
and fat emulsifiers. In hepatic insufficiency they render the bile less viscid
and cause an increase of normal bile acids; in gall-stone they may be preventive
and, by causing a copious outpouring of thin bile, may to some extent, prevent
bacterial invasion of the gall-bladder and hepatic duct and at the same time,
favor drainage of the bile channels. The use of bile acids and their salts is
more scientific than the administration of bile itself because they are the
physiologically active principle of this substance, and any danger from the
introduction of poisonous bodies from the bile, which really is an excretion,
is thus avoided. Of all the preparations sodium glycocholate, in ^ to 3 grain
(0.032 to 0.2) doses as frequently as is necessary, is the best. Both bile and
its salts are, however, uncertain in action.

Acid sodium oleate, like salicylic acid, is excreted by the epithelium of the
bile ducts and so assists in disinfection. Phenolphthalein, although a phenol
derivative, does not dissociate in the intestine to any appreciable extent; this
drug continues its antiseptic effect through the length of the intestinal tract.
If the acid sodium oleate is carefully prepared and is combined in a pill with
salicylic acid obtained from natural sources, i^ grains (o.i), phenolphthalein
I grain (0.065), ^^^ menthol, which is a carminative, acts as an intestinal
antiseptic, increases peristalsis and allays nausea, ^ grain (0.016) we possess
a very efficient means of combating gall-stone disease. This combination
is best prescribed, on account of the difficulty of obtaining the proper sodium
oleate and of manufacture, as probilin pills; 4 to 8 pills should be taken daily
in a full glass of hot water. Following this medication the elimination of
gall-stones of the hepatic variety is generally rapid. That the process may be
painless is best achieved by the administration of amyl valerate, 15 minims
(i.o) in capsule two hoiu-s before breakfast and after supper.

In the treatment of gall-stone disease we should consider that we are con-
fronted by an affection which is not purely due to the presence of a foreign
body but which is primarily a hepatic disorder. The removal of the calculi
is of little moment for even when this has been accomplished by surgical
means the patient is but at the commencement of his treatment, the object
of which is to remove the cause of the disease, a problem which is purely
medical. The congestions and inflammations in the portal area require
treatment and the correction of these and of the infectious catarrhs of the
bile ducts and gall-bladder and of the faidty bile formation in the liver is a
matter which is distinctly within the province of the physician.

Biliary colic with its agonizing pain often needs the hypodermatic admin-
istration of morphine for its relief; the patient may be kept lightly under the



468 DISEASES OF THE DIGESTIVE SYSTEM AND PERITONEUM.

influence of chloroform given by inhalation until the effect of the morphine
is evident. Amyl valerate in 15 grain (i.o) capsules repeated every 4 or
5 hours may prove effective and should, if possible, always be given in prefer-
ence to any opium derivative. It shoidd be hardly necessary to state that
the h)^odermic syringe should never be given to a patient. Antipyrine given
early in the paroxysm may prove useful and hot applications to the hepatic
region and hot baths are sometimes efficient in aiding the relief of the
pain. Gastric lavage has been suggested and may assist in the control of
thg nausea and vomiting; these latter, however, usually stop with the cessa-
tion of the colic. In mild attacks 8 minims (0.5) of tincture of belladonna
in a drachm (4.0) of spirit of chloroform may lessen the pain.

The surgical treatment of gall-stones, as previously asserted, should be
confined to those instances of the disease in which mechanical removal of the
foreign body is necessary, the procediu-e in each case being adapted to the
patient in hand. It is difficult to see how operation can do more than relieve
the condition present at the time of the undertaking for even removal of the
gall-bladder in toto can hardly prevent the further formation of calculi in
the bile ducts.

Ulceration of a gall-stone through the wall of the bladder or of the bile ducts
with acute symptoms such as those of peritonitis, of course, demands imme-
diate laparotomy.

NEOPLASMS OF THE GALL-BLADDER.

Cancer of the gall-bladder is infrequent; columnar or spheroidal-celled
carcinoma is the usual type. It is more frequent in men than in women and
is more often primary, the fundus being first involved. Secondary carcinoma
which has spread from growths of adjacent organs by contiguity has been
observed and involvement of neighboring structures in primary cancer of the
gall-bladder also occurs. In a very large majority of primary cancers gall-
stones are present, the latter being considered as cause of the former, probably
as a result of irritation; the calculi have also been held to be a result of the
neoplasm, the growth causing changes in the bile which favor their formation.

Symptoms. Jaundice occurs with involvement of the common or the
cystic duct but not unless these structures are affected. Other symptoms
are nausea and vomiting, haematemesis, melaena, pain and oedema due to
pressure. The pain is often paroxysmal and tenderness is frequently asso-
ciated with it. Cancerous cachexia may supervene.

A dense and hard tumor is palpable in the region of the gall-bladder and
when large, as often occurs as a result of dilatation of the organ or involvement
of neighboring structures in the growth, extends downward and toward the
mid-line of the abdomen.

Treatment. Medical treatment is palliative only. The pain may be



NEOPLASMS OF THE GALL DUCTS. 469

relieved by morphine or other less potent analgesics; the nausea and vomiting
may be controlled by gastric sedatives such as menthol, cerium oxalate, dilute
hydrocyanic acid, etc.; the bowels should be kept open by means of mild laxa-
tives and if intestinal fermentation exists the usual means should be employed
in its relief.

In order to be curative operation should be undertaken as early as possible
and before there is cancerous involvement of other organs. Post-operative
haemorrhage is frequent and is often responsible for death, consequently
radical surgical measures should be preceded for 2 or 3 days by the admin-
istration of calcium lactate or chloride in 20 grain (1.33) 3 times daily.

NEOPLASMS OF THE GALL DUCTS.

As is the case with malignant tumor of the gall-bladder, carcinoma is the
only type of grovi^th which affects the gall ducts. The condition is rare and
may be either primary or secondary. In the latter instance the primary
tumor is usually in the gall-bladder or in the liver itself. Jaundice is an early
symptom; it is persistent and usually extreme; the development of cachexia
is rapid. The gall-bladder is enlarged and may rupture. Pain and tenderness
are generally present. The diagnosis is difficult and often impossible without
exploratory incision. Gall-stones may be present, as in carcinoma of the
gall-bladder, and, as in this condition, have been held to be both the cause and
the result of the cancerous growth.

Treatment. The medical treatment is identical with that of carcinoma
of the gall-bladder. The itching, which is frequently associated with the
intense jaundice, may be relieved by weak phenol lotions or by means
of a powder composed of an ounce (30.0) of starch, a half ounce (15.0) of
zinc oxide and ij drachms (6.0) of camphor.

Operative treatment is difficult but it may be possible to remove the seat of
the disease in certain instances; recurrence after operation is not infrequent.
Carcinoma of the ampulla of Vater and of the duodenal papilla has been
removed, the divided end of the common duct being implanted into a healthy
part of the duodenum.

STENOSIS OF THE GALL DUCTS.

Occlusion of the gall ducts may result from cicatrization of an ulcer due to a
calculus; syphilis may be a cause in some instances; foreign bodies may also
reach the ducts through the duodenum and cause obstruction. Occlusion
due to the presence of the ascaris lumbricoides, to the echinococcus or to that
of liver flukes may occur but is rare. Obstruction also may follow pres-
sure from without which may be due to enlarged lymph glands at the
hilum of the liver or to tumors of neighboring parts. Congenital obliteration
of the gall ducts has been observed and is always fatal.



470 DISEASES OP THE DIGESTIVE SYSTEM AND PERITONEUM.

Symptoms. There is early enlargement of the liver with the symptoms
of obstructive jaundice. Later the liver may become small and is usually