CHOLELITHIASIS, GALLSTONE OR BILIARY COLIC, BILIARY CALCULI.

There is so much which may be said about the formation of gallstones and the troubles which they may produce that it is necessary here to epitomize as much as possible and to refer mainly to the surgical features of this condition. Gallstones are of all sizes, from the most minute to that of a hen’s egg, are present in numbers varying from a single calculus to thousands of calculi, are found commonly in the gall-bladder, in the cystic duct, or in the common duct, but occasionally are met with just escaping into the duodenum, through the duodenal ampulla, or in the smaller ducts of the liver or the main hepatic duct ([Fig. 627]). In at least 99 per cent. of cases they will be seen in one of the locations first mentioned.

Fig. 627

Gallstone presenting at the ampulla of Vater, i. e., endeavoring to escape into duodenum. (Pantaloni.)

Pages might be devoted to a discussion of the reasons for their formation. That cholesterin, their principal component, should more readily deposit in such a way as to produce these calculi, and more often in some individuals than in others, is hard to explain, but may be held to be largely due to its formation in excess in certain individuals and to concentration of those fluids which hold it in solution. Increase of cholesterin seems to be connected with catarrh of the membrane which produces it, and thus stagnation of bile may predispose. That bacteria have much to do with biliary calculi is now conceded, and a history of typhoid is obtainable in many cases. It has been shown experimentally that aseptic foreign bodies introduced into the gall-bladder remain indefinitely without becoming covered with precipitate, while virulent organisms set up disturbance, and only the attenuated or moderately infectious organisms produce calculi, and usually then only when some trifling foreign body is introduced at the same time. It will thus be seen that a nidus may be afforded by a clump of epithelial cells or débris.

It is not at present so much a question of what organisms are at fault, although they are usually the colon and typhoid bacilli and the ordinary pyogenic organism. It has been shown, moreover, that in typhoid fever the gall-bladder is often invaded, and that the typhoid bacilli may live there indefinitely, and that they tend to clump or agglutinate themselves in a very suggestive way into trifling masses which may serve as minute foreign bodies. Thus each predisposing factor reacts upon the other, and by a vicious circle either an acute lesion may be established or calculi may be formed in varying numbers.

Gallstones have been found in the newborn, but are relatively infrequent below the age of twenty-five, and are most common in the later years of life. The condition is by four to one more frequent in women than in men. The only predisposing habit seems to be such lack of exercise as gives no expulsive movement to the gall-bladder by action of the abdominal muscles. They are more common in the gouty and in those predisposed to uric-acid diathesis, while abundance of nitrogen seems rather protective. Biliary calculi have never been found in the wild carnivora.

McArthur has formulated the following conclusions of interest in this connection: