Biliary calculi are serious menaces to a patient’s welfare, not alone because of the obstructive symptoms which they may produce, but because of the acute or chronic conditions to which they indirectly give rise. These have been in some degree already mentioned. Thus cholecystitis and cholangitis of all degrees of severity, from the milder chronic forms to the phlegmonous and fulminating varieties, may be at least associated with the presence of such calculi and seem to be to a greater or less extent due to their presence. Around such foci of excitement there will always occur local peritonitis, which will result in adhesions, and the consequent tenderness with referred as well as local pains to which it necessarily gives origin. The viscera suffer not only in this direct way, but functional disturbances are produced, and are usually covered under those vague terms “dyspepsia” and “indigestion” with which patients crudely describe their discomforts, and under which physicians too often conceal their failure to appreciate the actual condition.
Furthermore there is always a possibility of cirrhosis resulting, because of distention of the hepatic ducts and backing up of the hepatic secretion. Thus the liver becomes larger and more dense, is colored green, its edges become more rounded, this occurring especially in the right lobe, or at least attracting more attention in that location because more easily recognized from without. Again the more acute inflammatory conditions sometimes cause paralytic ileus, or at least paralysis of the lower bowel, and thus lead to conditions almost identical with, and difficult to distinguish from acute intestinal obstruction.
Of equally great and growing importance is the fact that, according to Schroeder, some 14 per cent. of gallstone sufferers develop cancer, the presence of these irritating foreign bodies in the biliary passages having much the same relation to cancer of the liver as does the existence of previous ulcer to cancer of the stomach.
Symptoms.
—There is scarcely any morbid condition which is at one time characterized by such significant symptoms and at another by none at all as cholelithiasis. In rehearsing the list of the ordinary symptoms produced by the conditions exceptions should be made, for no matter how complete the list something may be omitted which has been noted in some particular case.
Gallstones confined within the gall-bladder proper may produce few or no symptoms, this being particularly true so long as the ducts are free and there are no persistent consequences of previous acute trouble. A stone may grow in the gall-bladder to a large size and cause little or no distress until it begins to work its way by the ulcerative process. Doubtless small concretions pass with little or no disturbance, or only that which would be considered a “temporary dyspepsia.”
When, however, gallstones produce symptoms these usually include more or less paroxysmal pain, occurring unprovoked and at irregular intervals, referred not alone to the upper abdomen, but radiating to the rest of the trunk, as well as in the direction of the right shoulder-blade. (The shoulder pains of biliary and renal lesions are due to the connection of the pneumogastric nerves with the ordinary sensory nerves above, and below with the sympathetic ganglia.) Attacks of pain are usually followed by nausea and vomiting, and if extremely severe by more or less depression and collapse. At times there will be a sensation as of distention in the region of the gall-bladder. Tumor in this location may or may not be present, and jaundice is an uncertain symptom, not occurring unless the ducts are occluded. The stomach so far sympathizes that digestion is at least temporarily disordered. In proportion as angiocholitis is produced by the passage of calculi we may meet with more or less septic features. The pain produced is uncertain in severity and duration, and is often relieved by the relaxation which may accompany or follow vomiting. After subsidence of severe pain there remains a dull ache for several days, lasting perhaps until another acute paroxysm. These pains are sometimes referred to the left side and over the stomach, in which cases it will usually be found that the gall-bladder is adherent to the stomach, while when the pain is felt in the right side of the thorax it is usually because there are numerous adhesions between the lower surface of the liver and the viscera below it. Such pain may even simulate angina pectoris or may involve the genitocrural distribution. In fact it may be referred to almost any part of the body.
Vomiting which is at first paroxysmal and colicky may become persistent, continuous, and even dangerous. It is essentially an expression of pneumogastric irritation. The vomited matter may contain bile or even, by retrostalsis, fecal matter. The depression which at first occurs may merge into complete collapse; it may even be fatal. It will necessarily be more marked when the paroxysms are more frequent.
A significant feature in nearly every case is muscle rigidity, especially of the upper abdominal muscles on the right side, but not necessarily confined to these. This muscle spasm is a symptom common to many serious conditions and is not of itself indicative. It simply implies a serious condition within. Tumor or enlargement in the region of the gall-bladder may be met with, but are by no means constant. These may become more pronounced with each attack, being reduced between times because of the escape of bile between paroxysms. It is a valuable symptom when noted, but no importance should be attached to its absence.
The presence of gallstones in the stools is, of course, indicative, but most valuable time is often wasted when waiting for their discovery. Moreover, a number of hours, or even days, may elapse, the time depending on the activity of peristalsis, between the escape of calculi into the duodenum and their appearance in the stools. A convenient way to search for them is to let the stool be stirred with a 1 per cent. solution of formalin and then strained through a sieve which has about sixteen meshes to the inch. The question of the wisdom of operation can practically always be decided without reference to the appearance of calculi. In this way the surgeon may feel that his diagnosis is corroborated by it, but in no sense weakened without it.