Reverend Sir,
Your respectful and most humble Servant,
J. Johnstone.
Kidderminster, Sept. 11. 1757.
THO’ it is now pretty well known, that colicky and icteric diseases often arise from gall-stones generated in the bilious receptacle, and obstructing its canals; yet an example of one, of such enormous size, voided into the duodenum from the ductus communis, as happened in the first of the following cases, is a very rare, if not intirely an unexampled occurrence. It will encourage us not too easily to despair of the expulsion of the largest calculi from the gall-bladder; and will teach us, that all violent attacks of pain about the stomach are not owing to gout reflected upon that organ: it will make us more cautious of giving drastic cathartics, heating and inflaming medicines, upon such a vague presumption; and ought to dispose those, who are trusted with the lives of their fellow-creatures, to a nicer observation of even the minutest symptoms and circumstances, which may occur in diseases.
The second case points out, under certain circumstances, the practibility of extracting, by incision into the gall-bladder itself, those calculi, which, from their figure, or other impediments, cannot be voided in the natural way. The method of performing this unusual operation, and some instances of its success, have already been made public in the Memoires de l’Acad. de Chirurg.
1. Mrs. F——, a sedentary corpulent old lady, had been much subject to colicky complaints, without jaundice, in the vigour of life. The seat of the pain was chiefly under the right hypochondrium, as high as the stomach. She had been tolerably free from it for at least eight years past. December 5, 1753, about eleven o’clock in the evening, she was suddenly seized with a violent pain, extending from that part of the stomach lying under the right side, thro’ to her back. She compared it to a sword driven in that direction. This pain continued not only with unremitted violence, but even increased, till seven o’clock in the morning: all this time she vomited and strained almost incessantly; but after her stomach was emptied of its contents, nothing came up besides clear slime, streaked with blood. About seven o’clock in the morning she felt her pain fall or move lower, as she expressed it, and from that time became remarkably easier. Soon after this change, she became extremely sick, and vomited up, for the first time, a prodigious quantity of greenish yellow bile. She had not before this seizure been remarkably costive; and in her pain had a free motion to stool with effect; but during the remainder of the (6th) day had none, tho’ all this time emollient clysters were injected; and she took regularly every two hours a powder of magnes. alb. terr. fol. tartar. tart. vitriol. ana ℈j. ol. nuc. mosch. gutt. j. with a draught of the succ. limon. & sal. absinth. But in the middle of the night, and all day (the 7th), she had an abundant discharge of loose bilious stools. She had continued free from excessive pain since the morning of the former day, only now and then complained of uneasiness sometimes in one, sometimes in another, part of her bowels. About twenty-four hours after her first seizure, she felt a great pain striking towards the bottom of her back, and one hour after voided the extraordinary calculus, of which the figure and description are subjoined. Some time after pieces of skins were voided by stool, which were evidently of the texture and appearance of the internal villous coat of the intestines and gall-bladder. The above medicines were the only ones she used, by my direction, under her painful complaint, excepting an external fomentation, and bleeding, which the hardness and contractedness of her pulse seemed to require. She was ordered to drink plentifully of thin broths, and other soft diluent liquors. During the course of her disorder she had no appearance of jaundice, nor since; and, considering her years, enjoys at present (Sept. 1757) very good health.
This calculus, as appears by the figure, was of a pyriform shape, resembling the form of the cystis fellea itself. Its surface was quite smooth and polished, excepting towards the base, at that part marked A, where it was scabrous, as if some other substance had lain contiguous to it. When broken through, it was composed of concentrical laminæ, which were alternately white and ochre-coloured. In length it measured one inch and three tenths; its transverse section measured at least seven tenths of an inch. It had a saponaceous smoothness, like other gall-stones, and floated upon water. It weighed only about 126 grains.
Tho’ it be difficult to conceive, how so bulky a substance, generated in the gall-bladder, could be conveyed along so narrow a passage as the common biliary duct, especially considering the obliquity of its insertion for near half an inch of length betwixt the coats of the duodenum; yet there seem sufficient data in the above case to prove, that this animal stone was not formed in the alimentary tube, but (large as it was) had come into it from the ductus communis choledochus.
The shape and saponaceous smoothness, and colour of the laminæ, of this substance, shew it was moulded in the gall-bladder, and formed from bilious particles. The severe pain and torture, and enormous vomiting, she underwent, for seven hours after her first seizure, argue, that it must then be lodged in some canal much narrower and straighter than the alimentary canal; for so soon as it dropped into that, the severe pain in a great measure ceased.
But that straight canal, in which it was situated during those seven hours of torture, could be no other than the ductus communis choledochus; for, during this space of time, no bile was emptied into the bowels, nor thrown up by the strongest efforts of vomiting. But no sooner had she perceived the cause of her pain to move or drop downwards (a sensation, which points out the precise moment the stone must have dropped into the duodenum), than she began to sicken, and instantly after vomited up a vast quantity of bilious matter; which now, from the de-obstructed duct, began to flow freely into the duodenum. The obstruction of the ductus choledochus was of too short a duration (only three hours) to occasion any observable jaundice. And it appears by the bloody flesh-like knots, thrown up with phlegm by vomiting, that the passage of the substance was not effected without considerable laceration of the small bilious ducts. And this easily accounts for the separation of the villous coat, which afterwards appeared in this patient’s stools.
