Pathological Physiology

Gallstones are formed in the gall bladder or larger bile ducts by precipitation from the bile of choles-terin, mixed with more or less mucus. Occasionally they contain the bile pigment (bilirubin) or calcium carbonate. Cholesterin is an alcoholic substance which may be extracted in varying amount from the blood or nervous tissues, especially the brain, and from the bile. It may be obtained in flat, rhombic, colourless crystals. Somewhat rarely it is excreted in the urine. It also exists in the waste matter contained in the lower bowel. Cholesterin is maintained in solution in the bile by alkaline salts, the sodium and potassium taurocholate and glycocholate. Calcium unites with the latter substances, forming new compounds with the biliary acids which are insoluble salts that no longer keep cholesterin in solution. When organic acids exist in excess in the tissues calcium is liberated, and on reaching the liver produces the above reaction.

An excessive accumulation of cholesterin in the system will result in its precipitation from the bile, and this occurs when for any reason the bile has long been retained in the gall bladder, where it has been concentrated by reabsorption of some of its fluid ingredients. Bacteria are undoubted agents in the formation of many 40 stones. The precipitation of cholesterin is favoured by the presence of a pre-existing hepatic stone or any foreign body in the gall bladder, such as an intestinal parasite, or its ovum, or thickened mucus.

Gallstones are oftenest present in advanced life and among those who adopt sedentary habits which lead to accumulation of bile in the bladder. On the latter account they are more common among females, and their occurrence is often related to excesses of the table, in regard to both food and drink.

All diseases of nutrition, such as long-continued dyspepsia, chronic rheumatism and gout, diabetes, and obesity, may be accompanied by the formation of biliary calculi.

Among other explanations given for the formation of gallstones is an excessive proportion of fat in the diet, although cholesterin is not true fat, but is really an alcohol allied to fats in some of its properties. Lack of exercise is a contributing factor.

Harley, who has given more careful attention than any other writer to the prevention of a return of gallstones by dietetic treatment, called attention to their greater prevalence in cold latitudes than elsewhere, and attributed this fact to the influence of certain foods, especially meat fat and suet. He wrote: "Starchy puddings and fat bacon cause more gallstones in this country [England], I believe, than all the other kinds of food put together".

The hydrocarbons are more completely consumed in early years than after middle life, and hence the greater prevalence of gallstones in the latter period, as above mentioned.

Bauer believes that " the formation of gallstones may often be referred to a faulty diet, for an excessive consumption of meat or free indulgence in fat and in spirits would probably favour their formation".

Less often gallstones are composed of pigment or of calcium carbonate, or of various mixtures of these substances with one another or with mucus. Individual stones sometimes attain the size of a small egg, and they may cause suppuration and the formation of a fistula from the gall bladder which opens into some other abdominal organ, or externally.

In many cases the stones exist in considerable number and size without giving rise to any symptoms or discomfort, but the smaller-sized stones occasionally find their way into the common bile duct, and their passage provokes intense agonising local pain, known as biliary colic.

Dietetic Treatment

From the above account of the manner of formation of bile stones it is evident that patients who have once suffered from biliary colic or other symptoms of the presence of concretions should exercise care in their diet and habits of life, in order to prevent the further formation of stones, and, if possible, to aid in dissolving those already present. The diet must be regulated with the object of lessening the production of cholesterin and of diluting the bile. Animal food may in itself contain cholesterin, and should therefore be taken very sparingly. A diet of concentrated animal food, by diminishing the alkalinity of the fluids of the body, favours the deposition of cholesterin from the bile, although this ingredient may not be present in abnormal amount in such food. Patients should be cautioned against excessive indulgence in any particular article of food, all richly cooked food must be given up, and if they are in the habit of eating nitrogenous food in excess, a larger proportion of fresh vegetables or farinaceous food should be substituted.

Calves' brains and the viscera of animals used as food in general, and particularly the liver, should be wholly interdicted. Sugars and fats must be forbidden in every variety.

Some vegetables, such as peas and carrots, are believed to contain material which closely resembles cholesterin. Carrots, moreover, are sweet, and sweet vegetables and fruits should be avoided, and also egg yolks, on account of the fat they contain.

Fresh green vegetables and acid fruits which, by virtue of their alkaline salts and organic acids, easily combine in the blood with alkaline bases should make the basis of the diet. The potassium salts which are contained in potatoes and other vegetables in abundant quantity are believed to be serviceable, because they retard the liberation of calcium/which, it has been shown, precipitates cholesterin. Bread and well-cooked cereals and fresh fish, except salmon and mackerel, may be eaten. Chicken or lean beef may be allowed, but all meat should be taken sparingly and not oftener than once a day.

For the purpose of diluting the blood and, through it, the bile, large quantities of fluid should be ingested, but it is best to avoid aerated waters and mineral waters which contain salts of lime. A tumblerful of hot water should be drunk at night, and another on rising in the morning. Champagne and other beverages which hold much carbonic-acid gas in solution must be avoided, as must malt liquors. Coffee, tea, and claret may be drunk in moderation. If the case is one in which considerable gastric catarrh or dilatation of the stomach is present, it is inadvisable to give much fluid by the mouth, and sometimes the desired result may be obtained by injecting salt water through a long flexible rubber tube into the colon. Intestinal irrigation as well as active purgation favours removal of the bile and prevents its accumulation in the gall bladder. Prout gives one or two drachms of sodium phosphate or sulphate daily to prevent concentration of the bile. For purgation the Carlsbad Sprudel salts and Saratoga salts are valuable.

In women tight lacing should be prevented, and the habit of sitting long in cramped positions which interfere with free hepatic circulation.

Large doses of olive oil, several ounces at a time, have been recommended for use during the passage of a gallstone, with the idea apparently of in some mysterious way lubricating the channels through which the stone is carried. But the oil, if absorbed, is taken up by the lacteals and emptied into the thoracic duct without going anywhere near the liver or bile passages, so that such an explanation of its use is absurd. The foreign bodies which it is claimed appear in the stools after giving oil in this manner have proved to be not stones, but inspissated masses of oil.