A PAPER 
ON 
CHOLE-LITH I AS IS, 
BY 
JOHN A. OCTERLONY, A. M., M. D. 
Read before the Kentucky State Medical Society at its Meeting in 
Louisville, Ky., April, 1877. 
PUBLISHED AT THE REQUEST OF T^/sipfSTT: 
LOUISVILLE: 
Printed for the Author by John P. Morton and Company. 
1877. A PAPER 
ON 
CHOLE-LITH I AS IS, 
BY 
JOHN A. OCTERLONY, A. M., M. D., 
Read before the Kentucky State Medical Society at its Meeting in 
Louisville, Ky., April, 1877. 
PUBLISHED AT THE REQUEST OF THE SOCIETY. 
LOUISVILLE: 
Printed for the Author by John P. Morton and Company. 
1877. A PAPER ON CHOLE-LITHIASIS. 
This name, derived from the Greek (XoXrj, bile, and hZos, a stone), 
is used to designate that state of the system in which biliary calculi are 
formed. This disease, without being one of the most frequent, is yet 
far from rare. A good deal of practical knowledge concerning it has 
already been accumulated, yet we must admit much remains to be ac- 
quired, and much is still shrouded in obscurity. 
The following paper is based upon the study of thirty-five cases 
observed and treated by me, and is offered as embodying the results of 
my studies and clinical experience with a disease which for years has 
been of deep interest to me. 
It has been suggested by several distinguished observers that the 
formation of gallstones depends upon a peculiar diathesis. In support 
of this view they allege that in many of these patients there is an evi- 
dent predisposition manifested by a constant formation of gallstones, 
and this in spite of all treatment; that the disease is often hereditary; 
that there is a certain close connection between the state of the system 
that induces the formation of gallstones and which results in the for- 
mation of urinary calculi; and, finally, that this constitutional state is 
gout. I have not been able to corroborate this view; on the contrary, 
I have been compelled 'to regard this disease as due to local or general 
causes entirely independent of any diathesis whatever. 
Some cases are rebellious, and obstinately resist all our efforts to 
cure; but when one reflects how difficult it is to continuously and 
completely control these patients, and when the various features of the 
disease are taken into account, this rebelliousness to treatment is more 
readily explained by the persistence of local causes without assuming 
the existence of a peculiar constitutional vice. 
In only two of my cases were any of their ancestors known to have A Paper on Chole-lithiasis. 
4 
had gallstones, and I therefore conclude that heredity plays but a 
feeble part in their production. Morgagni thought that hepatic colic 
in a patient subject to urinary calculi gave strong reason for suspecting 
the existence of biliary calculi, especially if the patient be an adult. 
Subsequent writers have noted the co-existence of these two forms of 
lithiasis, and have expressed a belief in their mutual connection. I am 
led to believe it is quite rare and incidental, for it was not observed in 
a single one of my thirty-five cases. Neither did I ever find any of 
the usual manifestations of gout in the persons I have treated for gall- 
stone. Gout is notoriously uncommon in women, but it is especially 
in them that gallstones are most often found. 
Causation. 
The etiology of gallstones is one of the “dark points” upon which 
much additional light must be shed before our knowledge concerning 
them can be satisfactory and complete. 
Age is one of the general conditions operating at least as a predis- 
posing cause. 
Gallstones are most common after middle-age. My oldest case was 
in a woman seventy-six years old; my youngest was another woman 
aged twenty-two. 
They have, however, been found in children ten and two years old, 
and even in new-born infants. These very young subjects did not, so 
far as I can learn, suffer from hepatic colic, and the presence of the 
concretion was only recognized after death. I do not know what is 
the earliest recorded age at which they have begun their travels and 
thereby occasioned trouble. 
Sex.—The greater susceptibility of women than men to this disease 
is well known. It is said to be in the proportion of three of the former 
to two of the latter. In my cases the difference was even more marked, 
being twenty-nine women to six men. 
Habit and Regimen. 
The majority of persons suffering from chole-lithiasis are large 
eaters> and fats enter prominently into their dietary. Jaccoud insists 
that they are generally corpulent. A tendency to obesity was noticed 
by me in thirty out of thirty-five. A sedentary life predisposes to 
chole-lithiasis by obstructing that process of tissue metamorphosis A Paper on Chole-lithiasis. 
5 
whose rapidity and perfection is so essential to health. It also pro- 
motes deposition of biliary constituents in the gall-bladder, which is 
strongly favored by too prolonged intervals between meals, and indeed 
by any retardation of the flow of the bile. Precipitation of the solid 
constituents of the bile may be determined by a variety of local con- 
ditions, which I will mention in detail. The general conditions just 
set forth act at most as a predisposing cause, which, without the action 
of a local cause, would be wholly inoperative so far as the development 
of gallstones is concerned. 
Diet undoubtedly has a certain influence in the production of gall- 
stones, both in man and in some of the lower animals. 
It has been observed that biliary calculi are more frequent in the 
gall-bladder of stall-fed oxen and sheep who have been fed on dry 
hay than in those who have been at pasture. I have inquired as to 
the occurrence of gallstones in horses with the hope of throwing 
additional light on the general etiology of this disease, but was sur- 
prised to learn that among them it is so rare that only one case has 
been recorded. Percival* believes this immunity is due to the sim- 
plicity of the biliary apparatus in these animals. 
Local Causes. 
1. Increase in the solids of the bile to such amount that the physi- 
ological solvent can no longer hold them in solution, the excess being 
thrown down and forming biliary calculi. This mode of formation is 
beyond the reach of demonstration, but one can readily conceive it 
to be possible, and certain facts render it quite probable. Gallstones 
become frequent at the age when the bile contains a larger amount of 
cholesterin, and Chevreul has shown that in several persons with chole- 
lithiasis the bile was excessively charged with fats.f 
2. A diminution in the amount of biliary solvents, cholate and 
choleate of soda and potassa, causing a precipitation of solids normally 
held in solution. This mode of formation is still less capable of dem- 
onstration than the former, but it is rendered probable by the effects 
that have been observed on administration of biliary salts in certain 
cases of chole-lithiasis. 
*0n the Diseases of the Digestive Organs of the Horse. London, 1855. 
t Jaccoud Pathologie Interne. 6 
A Paper on Chole-lithiasis. 
3. The presence of foreign substances in the gall-bladder. 
Dr. Thudicum* notes that in some cases the unclear part is com- 
posed of casts of the bile-ducts, and the central part often consists of 
small concretions of bile pigment which have fallen from the smaller 
ducts. A clot of blood, a globule of mercury, a fruit-stone, have been 
found as nuclei of gallstones. In one case the nucleus was composed 
of a lumbricoid worm, in another it was a pin. This is doubtless a 
rare mode of formation, but it does occur, which shows that when once 
a nucleus exists biliary matters tend to become deposited around it. 
4. Catarrhal inflammation of the biliary passages. 
This is the most efficient and probably the most frequent cause of 
gallstones. In health all the constituents of the bile are held in solu- 
tion, probably by the cholate of soda. But when catarrhal inflammation 
of the mucous membrane of the gall-bladder sets in, its solvent power 
is lost, the bile is decomposed, and its solids are thrown down either 
in the form of a pulverulent mass or larger particles, which tend to 
increase by continued accretion.^ 
Drs. Thudicum and Gomp. Bezanez have shown that when bile is 
allowed to stand for a long time in a bottle, acid decomposition takes 
place spontaneously and pigment hitherto dissolved is deposited. That 
the influence of catarrhal mucus in the gall-bladder plays an import- 
ant part in the decomposition and precipitation of bile, and the subse- 
quent formation of calculi is rendered still more probable by analogous 
changes in the urinary bladder, owing to cystitis, so familiar to all that 
more extended mention is superfluous. 
5. Another suggestion made by Thudicum is that decomposition of 
bile may also be due to a putrid ferment absorbed by the intestine; but 
of this I have seen no proof, nor of its agency in the production of 
gallstones. 
Catarrh affecting the biliary passages within the liver may, though 
rarely, produce a similar result as when affecting the gall-bladder. 
Structure. 
The usual seat of gallstones is in the gall-bladder. They are less 
commonly found in the cystic, hepatic, and common choledoch duct, 
*Thudicum on Gallstones, page 166. 
f Jaccoud loc. cit. A Paper on Chole-lithiasis. 
7 
and it is only seldom that they are found occupying the biliary canals 
within the liver. In this latter locality they are invariably quite small. 
Their volume varies from the small size of sandy particles to that of a 
hen’s egg, and even larger,* and is in inverse ratio to their number. 
When there is only a single calculus present it may fill the whole 
gall-bladder, and usually corresponds in outline to the form of the 
latter. The surface of the concretion may be rough or smooth, but 
the walls of its receptacle generally fit it closely, sometimes sending 
down processes of mucous membrane into the depressions which here 
and there furrow its surface. Multiple calculi, by reciprocal attrition 
and pressure, assume facet shapes and convex and concave surfaces, 
and thus come to fit perfectly together. Sometimes they present the 
form of regular tetra- or octa-hedral crystals. 
In consistence they may be firm or waxy, but are most often brittle, 
break readily between the fingers, and soon crumble either spontane- 
ously or on slight pressure. I have, however, in my collection, gallstones 
passed twelve and thirteen years ago, and which are still perfectly hard 
and intact. 
The material holding the particles together is thought to be cholic 
or choloidic acid, or both; it has also been supposed to be mucus. 
The color is subject to infinite variation; they may be whitish, 
brownish yellow, brown, green, blackish, mottled, or streaked. They 
are made up of many strata of different materials, and the differences 
in color between these various layers are often very great. 
The calculi have a nucleus, sometimes multiple, chiefly composed 
of biliary pigment in combination with lime, traces of mucus, and 
earthy phosphates. Around this nucleus the materials that constitute 
the concretion become deposited in regular or uneven strata. A ma- 
jority of the calculi are composed entirely of cholesterin, with a 
nucleus of calcareous matter, or pigment. Now and then this pig- 
ment is more abundant, and is sometimes uniformly distributed through- 
out the mass; at other times it and cholesterin form alternating layers. 
In some cases there is no cholesterin at all, and the calculi consist 
exclusively of carbonate and phosphate of lime. 
Uric acid\ has been found in them, and they generally contain traces 
of iron, manganese, and copper. 
* See an interesting case, with illustration, recorded in the American Practitioner 
February, 1877. 
-j- Stockhard and Marchand. 8 
A Paper ou Chole-lithiasis. 
The specific gravity is light, and varies with the composition; when 
chiefly of cholesterin they float in water. Ordinarily they are slightly 
heavier than this liquid, and sink in it. 
There may be fullness of the gall-bladder, and when palpation is 
practiced the calculi are felt as hard, movable bodies, producing by 
contact with each other, a crackling sound, which may be heard with 
the stethoscope, and is said to resemble the noise made by tapping 
upon a bag containing nuts or dry beans.* A large calculus can be 
accurately made out, as shown by Buckler and others. 
Biliary calculi being once formed may remain quiescent within the 
gall-bladder for an indefinite length of time. 
I have never seen a case where the diagnosis could be made under 
such circumstances, though it is sometimes practicable.f In certain 
cases, however, they do not remain latent, but give rise to disturb- 
ances of different kinds. 
i. The calculi excite irritation within the gall-bladder. Ordinarily 
they may exist even in large numbers without giving rise to changes in 
the mucous membrane; at other times they are merely the lesions pecu- 
liar to a catarrhal inflammation.f But in a smaller proportion of cases 
their presence induces suppurative inflammation, which may terminate 
in perforation, sometimes into the peritoneum, the stomach, the bowel 
portal vein, ureter, or into the pleura. But fortunately it is usually pre- 
ceded by the formation of adhesions to neighboring organs. This is 
especially likely where the opening takes place externally. Such a case 
came under my observation many years ago through the kindness of 
the late Dr. Lewis Rogers, who was so justly distinguished in life and 
so deeply mourned in death. The patient, a woman of middle-age, 
had for a long time suffered from dull, recurrent pains in the region of 
the gall-bladder. After a while she had sharp, shooting, and then throb- 
bing pains and fever. A swelling appeared, and an abscess formed, 
which broke e’xternally, and several gallstones were discharged through 
the wound. In time the opening closed and the patient recovered. 
Chronic inflammation may also be developed when the walls of 
the gall-bladder thicken and contract and the liquid contents become 
condensed by absorption of the water, and the gallstones become 
* Petit. 
fjaccoud Path. Int. A Paper on Chole-lithiasis. 
9 
welded together by a chalky mass lying in immediate and close con- 
tact with the contracted gall-bladder. 
2. The gallstones are disturbed and travel along the ducts, giving 
rise in their migrations to the symptoms of hepatic or gallstone colic. 
I have often found biliary calculi at the post mortem examinations 
of persons in whom their presence had never been suspected during 
life, and many persons pass small gallstones without any pain, especially 
at Carlsbad and Marienbad while drinking of these justly celebrated 
mineral waters; yet ordinarily the passage of one of these concretions 
is attended by characteristic and severe symptoms. 
Symptoms and Course. 
Calculi within the liver itself are even more likely to remain latent 
than when they quietly occupy the gall-bladder, but their symptoms are 
so extremely obscure that a diagnosis can scarcely be based upon them. 
Ill defined paroxysmal pains, not radiating, but confined to the right 
hypochondriac region, absence of jaundice, and hepatic enlargements, 
with, perhaps, slight digestive derangements, constitute their whole 
number. When an intra-hepatic calculus in its downward course 
becomes lodged in the hepatic duct there is fixed pain, persistent jaun- 
dice, with whitish evacuations, and the liver becomes speedily enlarged, 
but the gall-bladder is not distended, and this is a symptom of diag- 
nostic importance in differentiating between obstruction of the chole- 
doch duct and of the hepatic duct. 
It has already been mentioned that calculi may remain for a long 
time in the gall-bladder without giving rise to irritation, but in certain 
cases their presence induces chole-cystitis, sometimes so slight and 
superficial as to be unattended by any symptoms, while at other times 
involving the whole thickness of the wall of the gall-bladder and sig- 
nalized by acute symptoms of great severity. 
There are then severe pains in the region of the gall-bladder, con- 
stant, but with paroxysmal exacerbations, during which they radiate to 
the epigastrium, loins, and right shoulder, and also fever. 
The neck of the gall-bladder is of necessity implicated in the 
inflammatory process, and becomes obstructed; hence, to the symp- 
toms above related is added distension of the gall-bladder, which gives 
rise to a pyriform tumor in this region. But there is no jaundice, which A Paper on Chole-lithiasis. 
10 
is a point of importance as establishing the diagnosis between this con- 
dition and obstruction of the choledoch duct. 
Chole-cystitis ordinarily terminates in recovery, but may result in 
perforation and peritonitis, as already mentioned, with the alarming 
and grave symptoms that accompany that event. An interesting case 
of chole-cystitis from gallstones is reported by M. Paulet in Allg. 
Wiener Med. Zeitung, 1875, as follows: A woman aged 42, mother of 
eight children, began in November, 1874, to feel a severe pain in the 
right side. On examination there was found a somewhat diffuse tumor 
about the size of a child’s head, which extended from the umbilicus to 
the anterior superior spinous process of the ileum. As the case was 
attended by fever it was diagnosticated as one of suppurative ovaritis. 
In December it was determined to open the tumor with Vienna paste. 
In three days the skin was destroyed, and in seven the aponeurosis. An 
exploratory incision was now made, from which a little fluid escaped, 
but the needle came in contact with numerous hard bodies, which on 
removal proved to be gallstones. Forty of these were then taken out 
and a large one found almost encapsulated. It was broken, divided, 
and extracted without much difficulty, and some bile was also dis- 
charged. This biliary fistula soon closed, and in March, 1875, the 
patient had entirely recovered. 
It is difficult to understand why in some persons gallstones, even in 
large numbers, should remain in the gall-bladder without indicating 
their presence by any symptoms, and why in other cases they should 
be so often disturbed from their resting-place and urged along the 
various passages until finally ejected from the system. Speculation on 
this point is vain. 
There seems to be some connection between the inception of an 
attack of biliary colic and the period of greatest functional activity of 
the small intestine and neighboring parts consequent upon a full meal. 
The paroxysm ordinarily begins two or three hours after a meal, and 
patients are prone to believe that food has disagreed. 
When active duodenal contraction on the arrival of the chyme 
stimulates the gall-bladder to pour forth its contents the bile thus set 
in motion engages the calculus in the neck of the gall-bladder. When 
once entered into the cystic duct muscular contractions, aided by the 
vis a tergo of the bile, propel the calculus until it has cleared the ductus A Paper on Chole-lithiasis. 
choledochus and drops into the bowel. It has already been remarked 
that biliary sand and concretions of larger size may pass without un- 
pleasant symptoms, and even without the knowledge of the patient, 
but such is not the general rule. 
I have noted the symptoms of at least 150 attacks of gallstone colic, 
and though they were subject to great variation as to severity and dura- 
tion they were also characterized by great uniformity, so far as their 
number and character were concerned. 
(a) The earliest symptom is usually either shivering or a sense of 
discomfort and distress in the epigastrium. This is soon followed by 
(£>) nausea, vomiting, and (<r) pain. 
The nausea recurs in paroxysms, though it may be unremitting. 
The matters vomited consist at first of more or less completely digested 
food, but, continuing after the stomach has been completely emptied, 
the ejecta consisting of bilious, green-looking liquid. When the 
calculus has reached the choledoch duct the vomiting of this greenish 
liquid ceases, though the nausea and retching may not have stopped. 
Bilious vomiting, as suggested by Trousseau, indicates that the com- 
mon duct is free, and that the calculus is either at the neck of the 
bladder or in the cystic duct. 
The pain is, in most cases, at the commencement of the paroxysm 
referred to the pit of the stomach, and not to the liver. Subsequently 
it may radiate to the navel or the right shoulder, and become located 
more distinctly about the lower edge of the liver. The pain varies in 
character. It is described by patients as burning, cutting, tearing, or 
boring, or as a sense of painful constriction. It may be light, but is 
more frequently severe, and in a well-marked paroxysm it is excruciat- 
ing, with remissions and violent exacerbations, which are said some- 
times to occur in a regular rhythm.* 
Among all painful diseases I have observed there is none which 
entails more intense suffering than this, and women have repeatedly 
told me that they have endured far greater agony in passing a gallstone 
than in giving birth to a child. 
Some of my patients would in vain seek relief by frequent change 
of posture; others would remain perfectly quiet on their back, finding 
that every motion aggravated their sufferings. 
* Jaccoud loc. cit. A Paper on Chole-lithiasis. 
12 
Sudden and abrupt cessation of the pain, according to my observa- 
tion, most frequently indicates that the calculus has tumbled back into 
the gall-bladder after having engaged in the neck. Ordinarily, and 
especially when the calculus is large and angular, the mucous membrane 
of the ducts has been bruised and lacerated during its downward pas- 
sage, and though there is a sudden abatement of the pain when the stone 
drops into the bowel, yet perfect relief is not attained for some time, 
and tenderness and soreness continue perhaps for several days. The 
abdomen is often retracted, and its muscles may sometimes be seen to 
contract spasmodically. 
Jaccoud suggests that the abdominal muscles keep rhythm with the 
contractions of the gall-bladder, endeavoring to expel the calculus. 
The face is often pale, and the forehead covered with perspiration, the 
pupils are dilated, the pulse is often slow, but in many cases, and es- 
pecially when the paroxysm is severe and has been protracted, the 
pulse becomes small, quick, and irregular. 
The urine is often voided frequently and in large quantities, and is 
very pale and of low specific gravity during the paroxysm, but after it 
is over the urine becomes scanty, high-colored, contains bile and urates, 
and is of high specific gravity. 
In ordinary hepatic colic there is tio fever. I have, however, ob- 
served two cases in which well-marked febrile excitement set in and 
lasted throughout the paroxysm, then suddenly passed away with the 
cause. Frerichs reports similar cases in which the temperature rose as 
high as 104°, but the duration of the fever and paroxysm was exactly 
the same. 
When the paroxysm has lasted for some time distension of the gall- 
bladder may become quite perceptible. In my cases this was so rare 
that I find it recorded only in a case of protracted colic, lasting forty- 
eight hours, and in another case where the calculus became impacted 
in the common chole-duct, and which terminated in death. 
Dr. Hayden* also remarks that the round, smooth, yielding tumor 
mentioned by authors as formed by the distended gall-bladder is very 
rarely met with. In some when tumefaction of the gall-bladder was 
present there was also enlargement of the liver; both pass away to- 
gether as the obstruction is relieved, unless extensive inflammatory 
action has been excited. 
* Dublin Journal of Medical Science, April, 1876. A Paper on Cholelithiasis. 
13 
Jaundice. 
In twenty out of my thirty-five cases this symptom was never 
present, and among the fifteen cases in which it was observed it was 
not an invariable concomitant of the colic fits, these patients having 
many paroxysms in connection with which this symptom was absent. 
From this it appears that jaundice is not an invariable or necessary 
part of biliary colic. A calculus descending the cystic duct will not 
induce it, and even when the common choledoch duct is obstructed, 
jaundice sets in only if the impaction be protracted and the obstruc- 
tion is complete; if the latter, the jaundice is permanent. Such was 
the case with one of my patients, who died profoundly jaundiced and 
comatose. 
Most frequently the jaundice develops during the twenty-four hours 
immediately after the cessation of a paroxysm, and is then most likely 
due to tumefaction of the ducts from engorgement caused by the bruis- 
ing and laceration of the mucous membrane during the descent of the 
stone. 
Dr. Goodeve* has remarked that in some instances there are con- 
vulsive movements of the abdomen. This I did not observe in any of 
my cases, nor general convulsions or delirium, which are said some- 
times to occur in this connection. 
The duration of an attack of biliary colic varies greatly from a few 
hours to many days. I have had patients in whom it lasted forty-eight 
hours, and Trousseau records one case in which it lasted six months. 
It appears to be determined by the size and number of calculi passing. 
The subsidence of the pain which marks the close of the seizure is 
often sudden, but in my experience generally not complete. The 
patient complains of soreness and weakness; there is tenderness 
the liver and gall-bladder, and these in proportion to the duration and 
severity of the attacks. When the attack has been protracted, and 
when one follows another in rapid succession, I have often noticed 
steady and marked loss in weight. 
One attack of gallstone colic is, as a rule, the precursor of others. 
The frequency of their occurrence appears to depend, among other 
causes, upon the number of gallstones contained in the gall-bladder, 
* Reynold’s System of Medicine, vol. iii, p. 315. 14 
A Paper on Chole-lithiasis. 
and upon the rapidity with which new ones are formed. In some 
cases weeks, months, and even years may mark the intervals between 
the attacks. In other cases these recur within a few days, or even a 
few hours. 
In the latter class there are multiple calculi which migrate in rapid 
succession, or a single calculus repeatedly engages in the funnel-shaped 
orifice of the cystic duct, and then falls back into the gall-bladder; or 
it traverses the narrow cystic duct, and on entering the com. choledoch 
duct, which is of larger caliber, the pain greatly abates, and finally it 
engages the narrow orifice of the latter, when the pain again returns 
with increased violence, until the calculus at last clears it and drops 
into the bowel, and the fit is at an end. I have on several occasions 
been led to the opinion that a calculus having engaged in the orifice of 
the cystic duct had receded and fallen back into the gall-bladder. 
The following points have guided me in these cases: (a) The short 
duration of the seizure; (£) the sudden cessation of pain; (c) entire 
absence of jaundice during and after the paroxysm; (d) failure to find 
a calculus in the evacuations though careful search was continued for 
two or three days after the fit had ceased. 
But in many cases no such minute diagnosis is possible. Indeed 
the diagnosis of gallstone colic is often obscure, and the true nature of 
the disease is not seldom overlooked. An illustrative case occurred not 
long ago in a western city, the particulars of which were communi- 
cated to me by a medical friend, who performed the post mortem 
examination.* The gall-bladder was filled with biliary calculi; the 
duct com. choledoch was obstructed by a large concretion which had 
become impacted at the orifice of the duct, causing not only inflam- 
mation, but obstruction of the duodenum. 
# 
Gallstone colic may be distinguished from ordinary colic by the 
latter never being associated with jaundice; by the relief afforded by 
emetics and purgatives; by the pain being located further down, and 
by the absence of tenderness and soreness over the liver and gall- 
bladder. 
Renal colic is accompanied with irritation of the urinary organs, 
the course or microscopic appearance of blood in the urine, the 
course of the pain, retraction of the testicle, passage of gravel per 
urethram, etc. A Paper on Chole-lithiasis. 
In hepatic neuralgia the pain is far less severe. There is apt to be 
neuralgia in other parts with which it alternates; there is absence of 
jaundice, no enlargement of the gall-bladder and liver, and no gall* 
stones are passed. Hepatic neuralgia, besides, is exceedingly rare, and 
occurs mostly in hysterical women and in connection with neuralgia 
of other parts. 
Cancer of the pylorus has been mistaken for hepatic colic. I have 
differentiated them by noting that in the former the pain is more con- 
stant, though less severe; there is no jaundice, the liver and gall-blad- 
der are not enlarged, and the tumor, when pressed, is seated higher in 
the abdomen and nearer the median line than the gall-bladder. 
In carcinoma of the liver I have seen jaundice and enlargement 
of the gall-bladder from pressure of a cancerous nodule on the ducts, 
but the steadiness of the pain, the nodulated enlargement of the liver, 
the cachexia, and absence of the paroxysmal elements render the diag- 
nosis easy. 
Aneurism of the abdominal aorta and hepatic artery have been 
associated with paroxysms of excruciating pain, and jaundice, and even 
enlargement of the gall-bladder, and in some instances these lesions 
have been mistaken for gallstone colic; but aneurism in this locality 
is usually recognized without difficulty by attention to its character- 
istic signs. 
The only positive sign of gallstone colic is the finding of the cal- 
culus, or fragments of it, or biliary sand in the evacuations. Careful 
search for them should, therefore, always be made when their presence is 
suspected. Every evacuation for several days after the seizure should 
be kept for investigation. 
I generally prescribe a dose of some purgative the day after an 
attack of biliary colic, most often castor oil, which is indicated on 
account of the constipation that then commonly exists; and it has 
besides the effect of hastening the ejection of any calculi that may 
have found their way into the bowel. The method of search is a mat- 
ter of some importance. A double thickness of fine mosquito netting is 
tied over the top of a slop-bucket, the faeces softened and diluted by the 
addition of warm water should then be poured upon the netting. All 
solids, such as pieces of bone, undigested vegetable-matter, or gallstones 
are detained, while all the soluble portions filter through. When sought 16 
A Paper on Chole-lithiasis. 
for in this manner even small calculi can not escape detection. It is 
rather tedious and unpleasant work, but it should never be neglected, 
and rarely entrusted to others. In one case my diagnosis was hotly 
contested, and its correctness admitted only when, after two days’ 
search, a rather large calculus was found. 
If the calculus is large, round, or oval, with uneven surface and 
single it is probable that no others remain behind. If, on the con- 
trary, it or they be facet-shaped and polished, the gall-bladder will 
probably contain more that have not yet passed. The latter is the 
most common, and among the numerous biliary calculi that I have 
found only one had the appearance of being solitary. 
The Complications and Sequels 
Are sometimes of serious character, and require a somewhat more ex- 
tended mention than that already incidentally made. In my own 
cases unfavorable developments were very rare, and my knowledge 
of them is derived in part from dead-house experience in the hos- 
pitals to which I have been attached, and in part from acquaintance 
with writers on the subject. 
The calculi, whether in the liver, gall-bladder, or ducts, may give 
rise to inflammation, suppuration, and the establishment of internal or 
external fistula. The former are beyond our reach, but the latter have 
repeatedly terminated in perfect recovery, as shown by cases quoted in 
these pages. 
Rupture of the ducts or of the gall-bladder and general and fatal 
peritonitis happen occasionally. The literature of chole-lithiasis fur- 
nishes a number of instances, but it must be of rare occurrence. 
A calculus may become permanently impacted in the ductus chole- 
dochus, or this duct may become obliterated from inflammation excited 
by the passage of a gallstone. Under such circumstances there is en- 
largement of the gall-bladder, tumefaction of the liver, with enormous 
dilatation of the biliary ducts, which may form fluctuating tumors like 
abscesses. There is persistent jaundice, but sometimes the faeces regain 
their normal color, and the jaundice abates, because, under increasing 
pressure from behind, the bile filters through between the wall of the 
duct and the impacted concretion. 
Gangrene of the duct, followed by sudden death, has occurred.* 
* Bretonneau. A Paper on Chole-lithiasis. 
Even when the calculus has passed into the intestine all danger is 
not over. If large it may cause fatal obstruction of the bowel. Such 
cases have been related by Murchison (Diseases of Liver); by Cohn- 
heim (Virchow’s Archives, 1866) ; by Jeaffreson (British Medical Jour- 
nal, May 30, 1868). 
In other cases the calculus has been extracted from the rectum dur- 
ing life. Such a one was reported by Dr. Mitchell in the American 
Journal of Medical Science, 1866. 
If the calculi be small they may become arrested in the vermiform 
appendix and cause perforation and fatal peritonitis.* 
Dr. Dorkin relates a death from pressure of gallstones upon the 
vena portae. (Med. Times and Gazette, 1868.) 
A tendency to syncope is occasionally observed during the paroxysm, 
and proved fatal in one case reported by Portal in 1813. Another pa- 
tient, reported in the American Journal of Medical Science, 1866, by 
Dr. Buckler, of Baltimore, appears to have died from this cause; also 
a third, in which death occurred in sixteen hours. (Leigh, Medical 
Times and Gazette, 1867.) 
One of the rarest complications of chole-lithiasis is reported by 
Trousseau,f and consisted in reflex paraplegia, with general hyper- 
sesthesia of the skin, from which, however, the patient finally recovered. 
Prognosis. 
In the majority of cases this is favorable, but the possible occur- 
rence of such grave complications as those just enumerated must not 
be overlooked. Twenty-two out of thirty-five cases have passed from 
under my observation, but previously appeared to be permanently 
relieved; eleven still remain under my observation, and in all of these 
years have elapsed since the last seizure. Two died, as already stated. 
The length of time required to effect a cure is impossible to foretell. 
It depends in great measure upon the intelligent and hearty co-opera- 
tion of the patient. The disease runs no definite course, but may extend 
over several years. 
T RE ATMENT. 
The therapeutic indications are two-fold, viz.: (1) To relieve the 
patient during the attack, and (2) to prevent its recurrence. 
* Trousseau Clin. Med. 
■{•Clin, Med. A Paper on Chole-lithiasis. 
18 
To accomplish these objects is not always easy, and, as in almost 
every exigency, there is ample scope for the exercise of sound judg- 
ment and nice discrimination in the selection of means and methods 
appropriate to the particular case in hand. 
The agent that in my hands has been most uniformly efficacious 
for the relief of pain and prevention of shock to the nervous system 
is morphia. I have also thought that it tends to shorten the paroxysm, 
as well as to lessen its severity. It should be administered hypoder- 
mically. I usually give from one fourth to half a grain, and I repeat 
this every hour or two until the pain is relieved. The earlier in the 
seizure it is resorted to the more certain it is to afford speedy relief. 
In a recent article, on this subject Dr. Hayden, of Dublin,* con- 
firms, by his results, the opinion I have expressed about this remedy, 
and declares that hypodermic injections of morphine are more effica- 
cious than the inhalations of chloroform. 
Opiates should never be given by the mouth or in solid form for the 
relief of gallstone colic. 
In some cases I have treated, the pains were so atrocious that mor- 
phia was inadequate to allay them, and the administration of chloroform 
is then the best alternative. It may be given simply for the relief of 
pain and to induce such relaxation of the tissues as to thereby facili- 
tate the passage of the gallstone, and then the best method of using it 
is by inhalation. But the paroxysm may be so protracted as to make 
the continued inhalation of chloroform not only inconvenient, but 
absolutely unsafe, and I have more than once been compelled to dis- 
continue its use on such account. 
Chloroform is also given internally with the view of causing the' 
rapid solution of the gallstones in situ. Its administration in this 
way is based on the fact that chloroform is a powerful solvent of chole- 
sterin calculi out of the body, and upon the supposition that it is not 
changed in the blood and passes from this fluid into the gall-bladder, 
where its solvent action is exerted upon the contained calculi. 
One is inclined to reject at once this theory of its action as highly 
improbable. For it is indeed difficult to believe that a quantity of 
chloroform sufficient to dissolve these calculi in situ can be safely ad- 
ministered to a patient, even if the passage of the volatile liquid into 
the gall-bladder were at all proved. 
*Dublin Journal of Medical Science, April, 1876. A Paper on Chole-lithiasis. 
Dr. Buckler,* of Baltimore, has adhered to this treatment for over 
twenty years, and declares that he has invariably found it trustworthy 
and successful. He gave a teaspoonful of chloroform internally every 
hour while the pain lasted and a teaspoonful after each meal for five 
days longer, and saw a large calculus in the gall-bladder melt away 
under its use, so that at the end of this period the tumor had dis- 
appeared. 
Dr. John Barclay,f Physician to the Infirmary, Leicester, England, 
gives the same modus operandi and entertains the same high opinion 
of the value of chloroform administered internally in this disease, and 
declares that he has found it to give invariable and permanent relief in 
many instances. But his good results were obtained with much smaller 
doses than those given and advised by Dr. Buckler; two or three drops 
three or four times a day being all he gave. In my experience these 
large and frequent doses of chloroform produced alarming symptoms, 
and I have never been able to give them with the freedom recom- 
mended by Dr. Buckler. The smaller doses I have found utterly with- 
out effect. 
The general, prolonged hot bath I have sometimes found of signal 
benefit in producing relaxation and relieving pain, but it is often incon- 
venient, and perhaps as often impossible of access. Surrounding the 
patient’s waist with a folded sheet wrung out of hot water will some- 
times give relief, and in several instances I found the application of 
leeches speedily effectual when every thing else had failed. 
Jaccoud states that general blood-letting has in several cases been 
followed by sudden cessation of spasm of the ducts and subsidence of 
the attack. 
Emetics are often resorted to by the patient himself on account of 
the nausea and retching, which induce him to believe that if he could 
only vomit freely the pain, as well as nausea, would cease. But emetics 
ought to be rigorously proscribed, for if they do favor the progress of 
the gallstone by provoking more powerful contractions, they are also 
likely to produce rupture of the ducts. 
When the paroxysm is over I believe the administration of a pur- 
gative, such as castor oil, is advisable and hastens the ejection of the 
gallstone. 
*Amer. Jour. Med. Sciences, July, 1867. 
f British Med. Jour., 1870. 20 
A Paper on Chole-lithiasis. 
In order to prevent the recurrence of the paroxysms at least two 
conditions must be fulfilled : (a) Any gallstones remaining in the gall- 
bladder must be dissolved; (A) Formation of new concretions must be 
prevented. 
The well-known solvent powers of ethers upon cholesterin was sup- 
posed to be active within as well as out of the gall-bladder. Upon this 
principle the treatment for gallstones by means of Durande’s remedy 
was based. Trousseau, while rejecting the theory, accepted the remedy, 
which is composed of ether, sulph. giij, ol. terebinth, gij. Dose £ss in 
the morning, and gradually increased until about a pound of the mix- 
ture has been taken. At present this medicine is little used on account 
of its disagreeable taste, which soon becomes loathsome to the patient. 
I have never prescribed it. 
Success in preventing future paroxysms must depend upon our 
ability to arrest the formation of new concretions and to facilitate the 
expulsion of those already formed. 
So long as gallstones remain in the gall-bladder the liability to 
future paroxysms of colic continues, and this must be clearly explained 
to the patients. 
When our efforts are adequately seconded by the patient a cure can 
generally be effected so that no new gallstones will be formed. 
The patient’s food should be plain but nourishing. Highly sea- 
soned viands, malt liquors, fats, and sweets, and rich soups must be 
interdicted. He should eat moderately, at short intervals, not less 
than three meals a day. He should take active exercise, by walking; 
all other exercise is inferior to this. So long as any calculi remain 
in the gall-bladder he should not indulge in violent exertions, such as 
running, wrestling, etc. His daily life must be regulated with the view 
of establishing rapid and perfect tissue change, perfect combustion and 
complete and speedy elimination. 
Dr. Buckler, in the paper already mentioned, suggests that any 
remedy capable of preventing the formation of gallstones must be a 
highly oxygenated compound, and further states that the difficulty of 
dissolving cholesterin by any other substance than ether and chloro- 
form grows out of the fact that cholesterin contains a very small amount 
of oxygen, from to 2 per cent, which is less than that of almost any 
other substance. A Paper on Chole-lithiasis. 
21 
He proposed succinic acid and peroxide of iron on account of the 
large amount of oxygen contained in both of them, and had them 
made into a hydrated succinate of peroxide of iron. It should be 
taken for six months continuously at least, according to the following 
formula: 
R Hydrated succinate of peroxide of iron 
Distilled water 3 vjss. 
S. Teaspoonful after each meal. 
I have used this salt according to this formula, as prepared by my 
friend, Prof. E. Scheffer, of the College of Pharmacy in this city, and 
in almost every case with complete success. 
It has also been my practice to put the patients upon a course of 
Carlsbad water. Vichy or Marienbad waters have also been used with 
benefit. These waters are imported by Mr. C. L. Diehl, of this city. 
Artificial mineral waters of good quality are made by Wm. Springer 
& Co., and I have often prescribed them with excellent results. It 
is difficult to say how they act. At Carlsbad patients who drink the 
waters often begin without pain to pass gallstones, whose existence 
they had never suspected. 
As insufficient alkalinity of the bile and the prolonged stay in the 
gall-bladder of that fluid favor the formation of gallstones it is possible 
that these alkaline waters become remedial by provoking a more active 
and abundant percolation of highly attenuated and hyper-alkaline bile, 
which will prevent the deposition of bile pigment and the formation 
of calculi. 
The action of these waters upon catarrhal states of the mucous 
membranes may also have a share in their good effects in this disease 
which so frequently depends upon catarrh of the gall-bladder. What- 
ever their modus operandi may be, their curative value is undisputed. 
In my earlier cases I relied upon a remedy that was employed with 
much advantage by the late distinguished Dr. Lewis Rogers, of this 
city: 
R Ammoniae muriatis J-ss; 
Ext. taraxaci gss; 
Aquae 5jvj. 
M. Dessertspoonful ter in die. 
About four or five years ago Schiff, of Germany, suggested that 
gallstones are formed of cholesterin, not because this substance is 22 
A Paper on Cliole-lithiasis. 
formed in too great abundance, but because the bile is deficient in 
principles which maintain it in solution; these are soda and potash 
salts of cholic and choleic acid. Schifif therefore recommended that 
eight grains of choleate of soda be given twice daily, and increased 
unto saturation, as indicated by irregularity of the pulse, which becomes 
slow during repose and accelerated by the least effort. The dose may 
then be diminished, but not entirely suspended. It should be kept up 
at least a week to produce amelioration of leading symptoms. 
Dr. Dabney, of Virginia, has recently published some cases fully 
bearing out the previous dicta of Schiff. While on my eastern tour 
last summer I procured some capsules of the cholate of soda for a 
patient, but it so soon gave rise to gastric disturbance that we were 
glad to return to the use of succinate of the peroxide iron with Carls- 
bad water.