GALL STONES AND THEIR CONSEQUENCES CHOLELITHIASIS. 735 



gradually ; this is probably because the irritated nerves of the gall- 

 ducts are only gradually quieted, just as, when the eye is irritated by 

 a foreign body, it remains irritable for a time after the body has been 

 removed. Very rarely gall-stone colic terminates fatally with the 

 symptoms of excessive faintness, passing into true palsy. Somewhat 

 more frequently it is followed by the symptoms of permanent closure, 

 or of inflammation and ulceration of the excretory bile-ducts. 



Jaundice is not by any means a constant symptom of gall-stone 

 colic. There can be no obstruction and reabsorption of bile from im- 

 paction of the calculus in the cystic duct; and, as we have before 

 stated, even a temporary closure of the ductus choledochus does not 

 result in icterus. Usually, after the symptoms of impaction have sub- 

 Bided, there is a slight jaundice, which is very temporary if the impac- 

 tion in the ductus choledochus has not continued long. After reaching 

 the duodenum, the calculi are rarely vomited ; far more frequently they 

 are passed at stool, and this passage is only exceptionally accompanied 

 by abdominal pain or muco-bloody diarrhoea. It is almost always 

 unnoticed, so that the calculus is only discovered on careful examina- 

 tion of the fasces. After the attack has passed, we are often unable 

 to find any calculus, even if we place the faeces on a sieve and wash 

 them through it. In such cases the probabilities are that the impact- 

 ed concrements have gone back from the cystic duct into the gall- 

 bladder. 



There are still some dark points in our knowledge of gall-stone 

 colic. It is remarkable and unexplained that, in some persons, gall- 

 stones do not show any inclination to leave their place in the gall- 

 bladder, while in others they very frequently pass through the ducts. 

 We are not even clear as to how the calculi are pressed from the gall- 

 bladder into the cystic duct, although it is most probable that they are 

 floated onward, as it were, by the bile which is driven forward by the 

 contractions of the gall-bladder. This view is supported, among other 

 things, by the fact that gall-stone colic is particularly liable to occur 

 during digestion. Lastly, we would suppose that, during a gall-stone 

 colic, we might, from a variation in the intensity of the symptoms, dis- 

 tinguish three periods, the first corresponding to the impaction of the 

 calculus in the very narrow cystic duct, the second to its passage into 

 the somewhat wider ductus choledochus, the third to its impaction 

 again in the very narrow portio intestinalis of the ductus choledochus 

 but we usually observe nothing that can be referred to these phases. 



The inflammations and ulcerations caused by gall-stones do not in- 

 duce any uneasiness till the peritonaeum participates in the inflamma- 

 tion ; then we have the above-described symptoms of partial chronic, 

 and, occasionally, of acute peritonitis. The seat of the pain over the 



