In attempting to form any opinion on this subject we have therefore to take into consideration the history of the individual, as that may tend to show that the organ has been over-stimulated in past times, and may now be in a state of chronic disease ; his present habits, as informing us whether the bile-forming elements are supplied in too great or in too small quantity ; the appearance of the tongue, as that is very apt to present a dry fur in disorder of the liver; and the color, as well as the consistence of the evacuations from the bowels: we also derive instruction from the urine, which is more prone to deposit red sediments in bilious disorders than most others. (See Chap. XXXI., 8.) It is only when its due weight has been given to each of these considerations that we can interpret aright the sallow dingy complexion, the headaches, the disagreeable tastes in the mouth, the pains in the side and shoulder, and all the anomalous symptoms which such cases present.
§ 5. Gall-stones.—The gall-bladder may be full of these concre tions without giving rise to any symptoms: sometimes they are so placed as to act as a kind of valve, allowing a great accumula tion of bile in the gall-bladder, and preventing its proper evacua tion: sometimes they pass out unperceived ; but more commonly, when disturbed, their passage is attended with great pain, and occasionally they are arrested in their progress, become impacted in the duct, and can only make their escape by ulceration.
The pain which usually attends their passage is not difficult to recognize ; it is severe, tearing, or grinding, without tenderness ; referred to the pit of the stomach, and accompanied by a sense of constriction round the waist; it is not accompanied by fever ; the pulse is often slower than natural—the skin, during the severity of the paroxysm, being generally cold ; sometimes there is distinct rigor, almost always flatulence, nausea, or vomiting : then comes a lull, and after a longer or shorter interval the paroxysm of pain again and again recurs, until the concretion passes, or becomes fairly impacted. The more frequently it comes on, the greater is the probability of its being accompanied by tenderness ; but yet if we contrast the amount of tenderness with the severity of the pain, and consider that no febrile symptoms are excited, there is little chance of its being mistaken for inflammation. When jaundice supervenes it gives great confidence to the correctness of our diagnosis; but it is by no means a constant occurrence, because it is only when the stone is in the common duct of the liver and gall-bladder that it can prevent the passage of bile into the intestine, and so give rise to the discoloration of the skin.
The disorders which are apt to be mistaken for the passage of a gall-stone are chiefly two—in one the diagnosis is of much importance, in the other it is not very material: the one is local peritonitis excited by ulceration of the stomach, the other mere functional disturbance attended with flatulence, espe cially in nervous or hysterical persons. In one or two points peritonitis, occurring in connection with nicer of the stomach when the possibility of extensive extravasation is limited by local adhesions, is very analogous to the of a gall-stone : its sudden incursion, its severity, its position and perhaps the rigor at its first occurrence, are much the same in both eases : but they are manifestly distinct in the constancy of pain, in the tender ness from the very first, and the acceleration of pulse which invariably accom pany peritonitis. Functional disorder of the stomach, again. is so commonly accompanied by flatulence, and by pain as a consequence of distension, that were these the only symptoms, we should be constantly deceived by persons 'who exaggerate their sensations. We have to remember, however, that up to the moment of pain being produced by the entrance of the calculus into the duet, the patient has had no dyspeptic symptoms, no discomfort after meals, no flatulence ; it begins instantaneously : the pain of dyspeptic flatulence, on the other hand, has been gradually increasing in intensity for days or weeks, and it is only after some indiscretion in food, or along with some mental anxiety or cause of depression, that it attains the severity which can at all be mistaken for anything else ; and, again, the general symptoms, the coldness of skin and depression of the circulation, produced by the reality of pain, in the one case, cannot he simulated by the exaggerated expression of it in the other, nor can the paroxysms be readily imitated. Gout in the stomach, on the other hand, may chiefly be distinguished by its being a single seizure—not alternating in relief and exacerbation—by the diffuse character of the pain, and the absence of the sense of constriction so generally felt in the passage of • gall-stone.