PASSAGE OF GALL-STONES THROUGH TIIE NATURAL CHANNELS.—Gall-StOIleS may- remain for years in the gall-bladder without producing any marked symp toms, although bile-pigment may be found in small quantities in the urine. It may, as Dr. Adler has pointed out, pass into the circulation through the base of the ulcer. It is said that the presence of calculi can be made out by palpation and percussion, but sounding for gall-stones through the abdominal walls is now almost universally con demned as being more dangerous than a laparotomy.
Krauss recently described a prodromal state of cholelithiasis. The symptoms, more marked in females, are constipa tion, flatulenc3,-, loss of appetite, and a sense of pressure in the epigastrium. The skin of the face first becomes pale and yellowish, then yellowish brown. The lower portion of the conjunctiva is tinged yellow. The urine is scanty and with excess of uric acid. Bile-pigment, which is at first absent from the urine, afterward appears in small quantities. Bilious headaches and migraine are im portant symptoms.
When a gall-stone escapes from the gall-bladder, it is usually arrested for a time in the cystic duct on account of its narrowness and of the structure of Heister's valve. In the common duct a calculus may be arrested in any part of its course, most frequently near the duodenal extremity. In the first case biliary colic without jaundice is usually present, and in the latter colic with jaundice. It must, however, be remem bered that a calculus may pass through into the duodenum without pain or any other disturbance. This usually- hap pens when the ducts have been widened by the passage of stones previously.
Biliary Colic. — Premonitory symp tonis—such as those of dyspepsia, a feel ing of weight and distress with great restlessness—may be present. The onset is usually- sudden: a severe paroxysmal pain is experienced in the gall-bladder region, radiating upward to the right or left shoulder, across or down the ab domen to the thighs. The pain is, parox ysmal and increases in severity- until it reaches a climax. The patient becomes more and more restless, tossing upon the bed or throwing himself from the bed to the floor, rolling about in agony. When the suffering reaches its height, vomiting may occur, which may in turn, be followed by sudden relief. Intervals
of comparative ease may follow parox ysms of pain, and this may continue for hours and even days.
[Dr. H. B. Anderson, of Toronto, wit nessed the case (unpublished) of a woman, aged 50, who died after six months' illness. Had deep jaundice throughout ; also pruritus, with, latterly, chills, fever. and purpura. Suffered no pain. Had previous attacks of cholelith iasis with great pain, but no marked jaundice.
Autopsy showed well-marked catarrhal cholangitis. Gall-bladder thickened, dis torted, and atrophied, and contained a small quantity of bile. Common duct greatly dilated, had conical-shaped cal culus impacted at and partly protruding through the duodenal opening. (See wood-cut.) On bacteriological examination, the colon bacillus was found in the blood, spleen, and liver. J. E. GRATIANI.] The vomiting already mentioned curs toward the end of the seizure, in a large number of cases. The contents of the stomach are first expelled, and bile follows. In some instances the iting may be continuous and persistent, and may itself be a dangerous symptom. Two cases of persistent vomiting from calculi in the ducts, upon which tion was performed. In one the vomiting continued for days after the cause had been removed. The patient, however, made a good recovery. In the second the emesis had been so persistent that the patient had to be sustained by nu tritious enemata for four weeks previous to the operation. Afterward the vomit ing continued for two weeks, when death took place from exhaustion. Mayo Rob son (Allbutt's "System of Medicine").
The severity of the collapse varies in ,ditrerent cases. It is marked by cold, .clammy skin, pallor, and weakness and frequency of the pulse. It has, in some instances, proved fatal. Potain men tions acute dilatation of the right heart .as sometimes taking place in biliary Case of a woman, aged 47 years, who died suddenly in collapse, preceded by agonizing. pain, while under treatment for hepatic colic. There was found in the abdomen a. blood-clot weighing 600 grammes (20 ounces), and some san guinolent liquid. Pauly (Lyon Jan. 24, '92).