Case in which a tumor existed in the pyloric region fifteen months and was generally thought to be a cancer. It wa.,4 afterward shown to have been eaused by an enormous gall-stone, which ulcerated through into the duodenum and brought on symptoms of intestinal obstruction. A stone (weighing, 368 groins. 5 ',1,2 inches in circumference. and 3 inches. long) pa.ssed with some difficulty through the rectum. It was composed almost alto gether of cholesterin. Eleven months afterward the patient passed another stone weighing, 240 grains. Elsner (Med_ News, Feb. 5, '98).
Complications and Sequelm. — The most frequent complication of cholelith iasis is catarrhal inflammation of the gall-bladder and ducts. In fact this oc curs so often in the chronic form of the disease that it is generally- regarded as an integral part of it. Thickening of the walls of the ducts may take place to a sufficient extent to produce perma nent obstruction and chronic jaundice. Thickening of the walls and contraction of the cavity of the gall-bladder result in atrophy.
Sometimes the process ends in a fibrous perihepatitis, and the calculus will be found imbedded in a dense mass of connective tissue. These attacks are accompanied by more or less pain and tenderness in the hepatic region and by a slight elevation of temperature.
Acute phlegmonous inflammation of the gall-bladder is a rare disease. Cour voisicr described it under the term "Acute Progressive Empyema of the Gall-bladder," and collected notes of seven cases. This condition may exist when gall-stones arc not present, but it is usually a complication of cholelith iasis. Typhoid and typhus fevers, ma laria, and septicmmia are the usual pri mary diseases. The symptoms are those of a low, adynamic fever, rapid and feeble pulse, great depression, with ten derness and swelling over tbe right side of the abdomen. As a rule, general peri tonitis supervenes and death takes place. Occasionally it terminates in a peri hepatic abscess, which may be opened and a cure effected.
Pyogenic organisms may invade the crall-bladder when distended on account of obstruction in the cystic or common duct and give rise to suppurative chole cystitis and cholangitis. The patient experiences pain and tenderness in the hepatic region. A tumor more or less tender may be distinctly palpated. The general symptoms are, those of fever, viz.: irregular and high temperature, rapid pulse, and great loss of strength. The symptoms of pymmia may be present, viz.: rigors, heats, swellings, loss of appetite, nausea, vomiting, and great depression. This fever must be guished from Claarcot's hepatic mittent, in which there is no pus present.
Series of 14 cases illustrating compli cations arising from gall-stone disease:.
I. Impaction of stone in the cystic duet,. followed by hydrops, empyema, and eys to-duodenal fistula. 2. Sloughing of the, gall-bladder and formation of a fistula between it and the stomach. 3. Per foration of the gall-bladder and forma tion of a fistula betw-een it and the stomach. 4. Impaction of stones in the hepatic and common ducts. 5. Impac tion of stones in the common duet. G. Impaction of stones in the ampulla of \rater. 7. Primary carcinoma of the gall-bladder. When the snrgeon opens the abdomen for gall-stone disease lie must be prepared to meet and deal with any complication, and complications are met in from 20 to 30 per cent. of all gall-stone operations. -Moynihan (Brit. Med. Jour., Nov. 8, 1902).
Suppurative cholangitis presents the same general symptoms, but no tumor is felt, and the enlargement of the liver is more marked. Great tenderness may
exist over the hepatic surface. Persistent jaundice is a constant and marked symp tom.
As described by Naunyn, hepatic ab scess may- arise from cholelithiasis several different ways:— 1. An empyema of the gall-bladder may burst into the liver.
2. Purulent cholangitis of the intra hepatic ducts leads to ulceration, which may exist in different places in the liver.
3. The hepatitis sequestrans of Scbiippel.
4. Metastasis or embolic abscess.
Ulcerative endocarditis may arise from infection entering the circulation through the walls of tbe gall-bladder or ducts.
[The following ease, an example of this, -was seen by the writer, who is in debted to Dr. II. A. Bruce, the attending surgeon., for the notes here given: Mrs. A., aged 45, suffered fifteen years from recurring attacks of biliary colic. Dur ing last attack pyahnia developed, which ended fatally. Post-mortem: the bacillus coli communis was found in the heart's blood. Aortic valves were ulcerated and covered with vegetations. Gall-bladder contained six stones and its mucous membrane showed ulceration. through which it was thought the bacilli had gained entrance to the circulation. There W116 no evidence of chelangitis. J. E. GRAHAM.] Elfernorrhage is a complication which may occur as a result of the action of biliary toxins on the blood. Gastric and intestinal hTmorrhage may arise from this cause or from ulceration into the blood-vessels. Intestinal limorrhage may also be caused by passive conges tion, the result of thrombus of the portal vein due to the pressure of biliary cal culi. Naunyn has not observed copious llmorrhages from this cause.
Perforation of the gastric or intestinal mucous membrane is an occasional cause of hfemorrhage. The writer has ob served two cases in which he concluded from the history that hwinorrhage had arisen in this way; but he was not able to verify his conclusions.
In Aufrecht's case, quoted by Naunyn, a large stone had partially broken through from the gall-bladder into the hepatic tissues; this led to severe hmmor rhage, and the blood had entered the 1,a 1-bearer and thence bad flowed into the intestine along the cystic and com mon ducts. Ulceration of the portal vein and aneurism of the hepatic artery may also cause fatal hfemorrhage.
Diagnosis.—The diagnosis of the form of biliary colic produced by the arrest of gall-stones in the cystic duct is often difficult. The unbearable, cutting, tear ing, paroxysmal pain 5eated in the gall bladder region and radiating to the right or left shoulder is an important char acteristic. The presence of a tumor in the hepatic region, after an attack, of the characteristic shape of a distended gall-bearer is a confirmatory sign.
Of the conditions from which it is to be differentiated, the most frequent are: neuralgia, pleurisy, gastrie colic, intestinal colic, and appendicitis.
General diagnostic symptoms of chole lithiasis may be, primarily, pain, nausea, vomiting, jaundice, ashen-colored stools, high-colored urine, tenderness over the region of the liver, tumor, and nervous phenomena. Collectively, they establish the diaghosis. Separately, they may be found in other diseases of the biliary apparatus and surrounding viscera. IV. J. Means (Jour. Amer. Med. Assoc., Dec. 1, 1900).
PLEURISY.—The presence of pleurisy may be made out by careful physical examination.
NEURALGIA.—The painful points of neuralg,ia should be looked for.