This is often mistaken for cholelithiasis, although when the gall-bladder is opened only thick, ropy mucus will be found. This, as just remarked, may give rise to very painful spasm. The trouble when present is usually connected with similar trouble in the ducts. Moreover, around such a gall-bladder numerous adhesions are formed which give rise to much pain, tenderness, and local distress. Under these conditions the gall-bladder is enlarged and thickened.
Here, too, the curative treatment is essentially surgical, although pain may sometimes be temporarily relieved by aspirin in doses of from 0.5 to 1 Gm.
Cholecystitis obliterans corresponds closely to appendicitis obliterans, and is a condition characterized by a reduction in the size of the gall-bladder or its almost complete obliteration. In order to account for this it is seldom necessary to assume a congenital defect. The morbid process which produces it begins early, perhaps even during fetal life. The bile ducts are extremely small at birth and further stenosis is easily produced. The accompanying enlargement of the spleen will illustrate the toxicity of the condition which led up to it, and which may have occurred in infancy or early childhood. In a small proportion of cases early constriction of the ducts produced by local peritonitis and infection along the track of the umbilical vessels may account for the condition.
ACUTE CHOLECYSTITIS AND CHOLANGITIS SUPPURATIVA.
A suppurative condition within the gall-bladder is necessarily an expression of an infection, in nearly all instances proceeding from the intestine. The colon bacilli and those of typhoid are the organisms usually at fault. As has already been shown in the earlier part of this work they are facultative pyogenic organisms. Mixed infection with the ordinary pus-producing germs may also occur here. Such infections may spread through the walls of the gall-bladder and cause at least local and sometimes fatal general peritonitis. The condition is an especially frequent complication of typhoid fever, occurring sometimes relatively early, at other times after apparent recovery from the disease. In most of these instances it is supposed that the bacteria reach the gall-bladder by migration along the ducts, although direct penetration or infection through the blood is not to be denied. Impacted gallstones especially predispose to such infections. The result of all such cases is the formation and retention of pus—i. e., empyema of the gall-bladder—save in those rapid virulent or fulminating infections when it quickly becomes gangrenous, as does the appendix when similarly infected.
Symptoms.
—In acute infections of the bile passages patients suffer severe pain, made worse by movement, with general malaise, rapid loss of appetite and flesh, extreme tenderness over the gall-bladder and often around it, because of the accompanying local peritonitis. It is frequently possible to make out enlargement of the gall-bladder, which will move with the liver during respiration—this at least until it has become fixed by local inflammation—after which the patient will have thoracic rather than abdominal respiration. As such a case progresses local indications of disease will be added, with finally visible tumefaction and redness of the overlying skin. Jaundice is an uncertain feature, depending on the patulency of the common duct.
Pus when formed may escape and burrow in various directions; thus it may follow the suspensory ligament of the liver and appear at the umbilicus, or it may pass along other reflections of the peritoneum and appear about the cecum or above the pubes, or it may pass into the liver and appear as an hepatic abscess, or around it and thus give rise to a perihepatic or subphrenic abscess. It may even perforate the diaphragm and produce such collections of pus or such phenomena as have been described in the previous chapter, including empyema, pericarditis, abscess of the lung, etc. Again it may burst into the hollow viscera, stomach or intestines, or into the general peritoneal cavity, where it will cause speedily fatal peritonitis. Pulmonary abscess, with discharge of pus and bile, has been cured by Mayo Robson by removing a stone from the common duct. Gallstones have also been found in the pleural cavity and have even been passed by the mouth. Finally pus collecting in the right abdominal pouch may also be mistaken for perirenal abscess.
Acute phlegmonous cholecystitis, with gangrene, corresponds to the fulminating form of gangrenous appendicitis, and only received its first description in 1890 by Courvoisier. This is not common, but when met with becomes a disastrous lesion. It is essentially a still more virulent expression of infection and consequent necrosis than the condition described above. It may be so rapid as to destroy the gall-bladder before it has had time to fill with pus. It may occur with or without a history of previous trouble, in the absence of which a diagnosis will be made more perplexing. As the condition declares itself and progresses there will usually form about its site a protective barrier of lymph and omentum, which may prove, when present, the salvation of the patient, especially if the surgeon who makes the operation, and this should be early, recognizes the value of these protections and does not break them down. The condition occurs in connection with gallstone disease, but may follow typhoid fever, cholera, puerperal fever, or other intense infection.
Symptoms of gangrenous cholecystitis are essentially those of the less severe types of infection, only more pronounced. They include severe pain of sudden onset, rapidly growing worse, spreading over a larger area, extreme tenderness and muscle spasm, rapid thoracic respiration, quick pulse, intense depression and collapse, vomiting, rapidly increasing tympanites, anxious facies, with every expression of intense sapremia. Jaundice is an inconstant symptom, while fever is usually present, but is of little importance. The disease may be so rapid as to quickly kill. At all events local destruction occurs early, either with abscess or gangrene, or both.