On the relief of pain and the absence of evidence of the passage of the stone, the question crops up of the wisdom of administering drugs with the view of aiding its expulsion or effecting its disintegration. In common duct obstruction the physician can be usually certain of the lodgment of the stone when deep jaundice supervenes, but he should remember that this does not follow cystic duct blocking, which, however, shows itself by considerable enlargement of the gall-bladder.
Of the drugs believed to have a specific or solvent action on the stone Salicylates occupy a prominent place; 2o-gr. doses of the sodium salt three or four times a day render the bile more fluid, and are consequently administered as a routine to aid in its solution.
Benzoate of Soda appears to possess similar action, and Glycerin was formerly much used.
Olive Oil is largely administered for this purpose; 4 to 8 oz. or even more may be given once or twice a day. Obviously it does not enter the ducts till after digestion, when a portion of it is converted into a soap or fatty acid; this is believed to cause disintegration of the cholesterin mass composing the calculus. The number of cases in which this treatment has succeeded in the hands of many physicians warrants a trial of the drug in all instances before resorting to operation. 1 t should be given when fasting. Oleic Acid and Soaps made from it are also administered, and salts of the Bile Acids are sometimes given (5 grs. Sodii Taurochol.) in Keratin-coated pills, or Ovogal with great advantage. Turpentine and Ether (Durande's cure) are also vaunted, but there is little evidence of their value.
Chologen, which is believed to be a mixture of Calomel and I'odophyllin, in tablet form is greatly used on the Continent.
Alkalies exercise some solvent action, and there can be no doubt of the efficacy of the Carlsbad and Vichy Waters when freely administered at the spas, and a resort to Carlsbad in chronic cases is a routine recommenda tion with many physicians.
Drugs and agents are sometimes employed with the view of exciting peristaltic action in the common and cystic ducts. Thus a large dose of Calomel (so to t 5 grs.) followed by r oz. Castor Oil is occasionally effica cious in expelling the contents of the gall-bladder, and many instances are on record where numerous calculi large and small have been cleared out by this method. It is nut, however, a safe practice to follow where a large stone has recently lodged in the common duct and caused deep jaundice. Its best results are seen in chronic cholelithiasis, where the gall-bladder contains calculi which are not actively blocking the cystic duct, and the writer has several times seen operative procedure rendered unnecessary in cases where this had been already decided.
Massage and " pumping movements " with the view of dislodging the stone are to be condemned. The Faradic current with one pole over the gall-bladder and the other on the spine has been recommended with the view of exciting strong peristaltic action in the gall-bladder and ducts, and it may be tried without risk of rupture.
Surgical Treatment.—There is a consensus of opinion that surgical measures should he resorted to at earlier stages than has been the practice of former years. Operative interference is considered justifiable under the following conditions : (1) In gall-stones impacted in the common duct associated with persistent jaundice and repeated attacks of pain. (The period during which medicinal remedies are to be persevered with must be decided upon by the severity of the general symptoms and the condition of the patient, but it is safe to say that the mistake is still frequently made of delaying too long before operating.) (2) When attacks of hepatic colic with or without jaundice occur repeatedly. (3) When the gall-bladder is markedly enlarged without jaundice. (4) When the gall-bladder is enlarged and jaundice is present, if cancer is probably not the cause. (5) In all suppurative conditions of the gall-bladder. (6) In all cases where infective cholangitis is present. (7) In cases where biliary fistula: have formed.
The nature of the operation required will depend upon the physical conditions discovered when the abdomen is opened. Thus, if the stone be found blocking the common duct high up, the operation of Choledocho tonzy or Choledocho-lithotomy is performed. This consists in incising the duct over the calculus as the latter is grasped between the finger and thumb, and after its extraction, the duct being explored for the presence of other stones, the wound in the wall of the biliary passage is to be either care fully sutured or drainage provided by the introduction of a rabber tube. When the stone is found firmly impacted in the ampulla of Vater the operation of Duodeno-choledothotomy should be performed. This consists in opening the duodenum by a vertical incision, and after enlarging the orifice of entrance of the duct the stone is delivered through the opening. In all cases of stone in the common duct not only should this be carefully explored, but the gall-bladder must be examined and any calculi found in it must be removed at the same time. Formerly in some cases the opera tion of Cholelithotrity has been successfully performed without incising the duct, the stone having been crushed by padded forceps or broken up by inserting a needle—an operation not to be recommended.