'298 THE TREATMENT OF DISEASES. 



The attack usually comes on after the principal meal of the day, or after some 

 severe muscular exertion or shaking of the body. Sometimes the patient is fore- 

 warned of his approaching trouble by a feeling of sickness, with much flatulence and 

 an unusual disturbance of the nervous system. In many cases he is seized suddenly 

 with violent pain, but more commonly it is moderate in its onset, and gradually 

 increases in severity. The pain usually starts from the pit of the stomach, and 

 spreads upwards perhaps to the shoulders, but never downwards. It is usually of 

 two kinds a dull, aching pain, which is constant, and an acute, agonising pain, 

 which comes on by fits and starts. The pain is often so excruciating that a strong 

 man rolls on the ground in his agony. Sometimes he bends himself nearly double, 

 changing his position every moment in the vain endeavour to obtain some relief from 

 his sufferings. The pain may be so intense as to cause strong convulsions. At the 

 onset it is relieved by pressure, and the patient keeps his hands applied to the pit 

 of the stomach, or rests perhaps the weight of his body on some hard substance 

 placed beneath his stomach. Subsequently there may be intense tenderness of the 

 abdomen, probably in part due to the repeated straining and retching. The paroxysms 

 if frequent and protracted induce great lassitude and exhaustion, the face being pale, 

 the pulse slow, and the whole body covered with a profuse sweat. With the pain 

 there is generally much nausea and vomiting, and sometimes hiccup, and the 

 matters vomited are usually very sour. The patient is flatulent and dyspeptic, 

 languid and gloomy. Sometimes inflammation arises, and then the pulse becomes 

 frequent, and the skin hot, and thirst and headache are complained of. Most 

 commonly there is jaundice, but not always, for the stone may be angular in 

 shape, and permit the egress of bile. At length, however, the concretion passes 

 into the bowels, the pain suddenly ceases, and all is soon well again. When 

 once a large calculus has forced its way through the duct, this remains per- 

 manently dilated, and smaller stones may afterwards be voided without pain or 

 trouble. Some people get rid of scores of gall-stones in this way in the course of 

 their lives. Generally the stones are voided with the stools, and they should always 

 be looked for. It is a great satisfaction to find your enemy, and make sure that 

 you have got rid of him. If you don't see the calculus, you can never be absolutely 

 sure that it has not fallen back into the gall-bladder, instead of getting through the 

 duct. You must remember that in some cases the stone may not be passed for 

 some days after the sudden subsidence of the pain. You will have to exercise a 

 certain amount of care and attention in looking for the gall-stone in the motions. 

 As we have seen, gall-stones when dried readily float on water, but they will not 

 do so in their natural condition. It is not enough, therefore, to mix the faeces with 

 water, and trust to the calculus floating up to the top, for it won't. It is necessary 

 that the whole of each alvine evacuation should be carefully passed through some 

 kind of fine sieve. It may be a disagreeable thing to have to do, but it is a great 

 satisfaction to find the stone, and make sure of it. In one case, a man collected 

 fifty-five small biliary calculi, which he voided within the space of five weeks. 



When concretions pass which are small and angular, having several flat surfaces, 

 the trouble is probably not over, and more may be expected. If a single stone come 

 away, large, smooth, and roundish, we may trust that there are none left behind. 



