The jaundice of cholelithiasis is gen erally more or less intermittent in char acter, differing, in this respect, from that of cancerous obstruction, which is usually progr, essive. Jaundice may con tinue some days after the stone is ex pelled, when thickening of the wall may still cause obstruction.
The presence of bile-pigment in the blood does not appear to cause any con siderable disturbance of function and in any case is only slightly poisonous, The bile-acids, on the other hand, when they enter the blood act as virulent poisons on the nervous and muscular systems and on the blood-corpuscles, as first shown by Dousehe. Thoma ("Path. and Anat.," vol. i, p. 29).
[This statement is not altogether in accord with the views of Bouchard, who regarded the bile-pigment very poison ous., and who ascribed its comparatively mild effect to the fact that it is either absorbed by the tissues or rapidly given T al, ATI,. 1 Gall-stone attacks are frequently ac companied by fever, and in some in stances the temperature may rise to 104° F. In such cases there is usually a. rigor, followed by great heat of skin. The sweating stage is often absent. This. has been called hepatic-intermittent, and is probably of the same character as. that which sometimes follows the pas sage of instruments through a con stricted urethra. The fever is thought to be reflex by some, but it is more prob ably the result of toxin absorption.
The length of time required for the calculi to find their way through the cystic and common duct varies in differ ent cases. They may pass through so rap idly and easily that obstructive jaundice. may not occur. Again, they may remain months in the ducts causing very fre quently' incomplete obstruction. This is 'termed by some the irregular form of oholelithiasis.
In some cases the calculus floats in a distended portion of the duct, usually the ampulla of Vater, causing an in termittent or remittent jaundice.
Fenger agrees with Courvoisier that gall-stones in the common duct give rise to a series of special symptoms by which the situation can often be diagnosed with a fair amount of certainty. Some of these symptoms and conditions are:— 1. Atrophy of the gall-bladder and
absence of tumor.
2. Presence of icterus, which may be (a) intermittent: complete freedom from jaundice when the calculus passes into the duodenum. (b) Remittent jaundice is usually caused by a floating gall-stone acting as a ball-valve.
3. Colic. Localization of pain out side of the gall-bladder region indicates stones in the common duct. Remittent pain is the sign of a stone floating in a dilated portion of the duct. This pain is sometimes relieved by change of posi tion.
Intermittent or remittent fever.
Histories of a number of cases. In one of these the first attack of colic with ieterus had occurred two years before. These attacks then became more and more frequent and were accompanied by slight remittent icterus. There was also remittent pain every two or three days for three weeks. followed by fever, ic terns graris, and death. The autopsy re vealed one small floating stone in the dilated common duet.
In a second case the first attack of binary colic had taken place two years previously, followed by icterus. Second attack occurred on October 24th, fol lowed by lighter attacks, loss of weight, slight icterus, but no tumor. Operation of eholedochotomy. One stone, two cen timetres in diameter, was removed; DO leakage; recovery. The patient gained fifty pounds in three months. Fenger (Amer. Jour. Med. Sci., p. 286, '97).
Symptoms of a gall-stone in the am pulla of Vater acting as a, ball-valve. Chronic jaundice, rarely- deep, varying in intensity, at times almost or entirely disappearing, to deepen invariably after a paroxysm of pain. Often a constant sense of discomfort, which may be ago nizing or griping or like an ordinary liver-colic. Fever occurring in parox ysms; chills may be quotidian or ter tian in type. The spleen usually enlarges with the febrile paroxysms. Although lasting for months or years, the health may not be much affected, the patient being able to work between the parox ysms. Such eases are often diagnosed as chronic malaria, abscess of the liver, or suppurative cholangitis. Osier (Lan cet, May 15, '97).