MDfBGALL-STONES ANDDISEASESOFTHEBILE-DUCTSJ.BLAND-SUTTON,F.E.C.S.ENG.SURGEON AND LECTURER ON SURGERY TO THE MIDDLESEXHOSPITAL,AND MEMBER OF THE CANCERINVESTIGATION COMMITTEEWITH FIFTY-THREE ILLUSTEATIONSNEW AND REVISED EDITION514494.soJAMES NISBET &CO.,LIMITED22,BEENEESSTEEET,W.1910PRINTED BY ADLARD ANDSON,LONDON AND DORKING.PEEFACE TO THENEW EDITIONIPVUKINGrthe last fiveyearsourknowledgeof thediseases of thegall-bladderand bile-ductshasundergoneacomplete change.Observationsinthepost-mortemroom and in theoperatingtheatrehave ledphysiciansandsurgeons astray.Theopinionthatmanydiseasesassociatedwithgall-stonesare due to infectionsascendingthe bile-ducts fromthealimentarycanal hasprovedto be wide of themark.Experimental pathologyteaches that theliver is anorganicfilter as well as alaboratory.Manyserious diseases of the bile-ducts are causedbyinfectionfromcontaminatingelements eliminatedfrom the blood of theportalcirculation and dis-chargedinto theoutflowingbile. Themajorityofthe disturbances which come under thesurgeon'scognisancein connection with thecanal-systemofthe liver are"descendinginfections."Thecolonisation ofthegall-bladder bytheBacillustyphosusis afrequent sequeloftyphoidfever,andthediscoveryof"typhoid-carriers"has served towidenourviewinregardto theoriginofgall-stoneTenyears ago primarycancer of thegall-bladderIV PREFACEwasregardedas an uncommondisease,but theroutine examination ofgall-bladdersremovedduringlifeappalsusbyrevealingitsfrequency.Criticalanalysisof the clinical andpathologicalobservationsbearingon the association of cancer andgall-stonesindicates that these twoconditionsaremanifestationsof acommoncause. Itstrengthensthepositionofmen who believe that cancer is due to a micro-parasite,andespeciallythose whosuspectthat theinfecting agentis admittedinto thealimentarycanalwith food and water. So far as theexcretoryapparatusof theliverisconcerned,themicro-parasitein thealimentarycanal isconveyedto the liverbytheportalcirculation;it is thenexcretedandcan-ledbythe bile to thegall-bladder,where it infects andstimulates theepitheliumto unnaturalgrowth.Thisnewknowledgeis set forth in this newedition.JOHN BLAND-SUTTON.47,BROOKSTREET,LONDON,1910.PREFACETOTHEFIRST EDITIONHPHIS little book consists of a series of lecturesdelivered at tlie MiddlesexHospital.Iventuretopublishthembecause I am under theimpressionthat cholelithiasis isinadequatelyconsidered in text-books ofsurgery,and the availableEnglishmono-graphson thissubjecthavegrowntoobigto beuseful for students.Since Tait'spioneer operation (1876)the litera-turerelatingto theoperativetreatment ofgall-stones has becomebewilderingin itsmagnitude: inspiteofthisactivitymanysufferersfromcholelithiasisfind theirwayinto the deadhousewith their diseaseunrecognisedand unrelieved. I do not contendthatsurgeryisunerringinrelieving"gall-stonepatients/'for in the lastchapterwill be found astatistical record(gatheredfrom returnskindlyfur-nishedmebytheRegistrars)ofoperationsperformedfor the relief ofgall-stonesin thegeneral hospitalsofLondonduring1905. This record showsthat,evenwith the assistance of"asepsis," operationsonthegall-bladderand bile-ducts cannot be describedas free from risk.1907.CONTENTSCHAPTERPAGEI. THE BILE-DUCTS AND THE BILE . . 1II. TYPHOIDINFECTIONOFTHEGALL-BLADDER 17III. INFECTIONSOFTHEBILE-DUCTSANDGALL-BLADDER(CHOLANGITISAND CHOLE-CYSTITIS)23IV. CONGENITAL OBLITERATION OF THE EX-CRETORY APPARATUS OF THE LIVER . 41V. GALL-STONES : THEIRFORM, STRUCTURE,COMPOSITION,ANDMODEOFFORMATION 50VI. THE PATHOLOGICCONSEQUENCESOFGALL-STONES ...... 67VII. THE CHANGES GALL-STONES PRODUCE INTHE BILE-DUCTS..... 90VIII. INTESTINAL OBSTRUCTION FROM GALL-STONES(GALL-STONE ILEUS). . . 107IX. CYSTS ARISING FROM THE INTRAHEPATICBILE-DUCTS 121X. EPITHELIAL TUMOURS OF THE GALL-BLADDER AND BILE-DUCTS 130Vlll CONTENTSCHAPTER PAG:XI. THE EFFECTS OF SOME FORMS OF PAN-i;I:\TIC DISEASE ON THE EXCRETORYAPPARATUS OF THE LIVER . . 149XII. THESYMPTOMS, SIGNS,AND DIAGNOSIS OFCHOLELITHIASIS . ... 164XIII. DIFFERENTIAL DIAGNOSIS OF CHOLE-LITHIASIS . . 182XIV. TREATMENT OF CHOLELITHIASIS . . 192XV. OPERATIONSONTHEEXCRETORY APPARATUSOFTHELIVER . . . 201XVI. OPERATIONS ONTHEEXCRETORYAPPARATUSOFTHELlVER(cniiliitiK'il). .212XVII. OPERATIONS ON THE COMMON BILE-DUCT224XVIII.AFTER-TREATMENT, KISKS,ANDSEQUELJEOF GALL-STONE OPERATIONS . . 232XIX. INJURIES OF THE GALL-BLADDER ANDBILE-DUCTS . . . 242XX. THE MORTALITY OF OPERATIONS PER-FORMED FOR THE RELIEF OF GALL-STONE DISEASE .....247INDEX 251ONGALL-STONESANDDISEASESOF THEBILE-DUCTSCHAPTER ITHE BILE-DUCTS AND THE BILEINeverychemicalindustrythere are wastepro-ducts,andgreatingenuityisoften exercised in orderthattheymaybedisposedofeasily, economically,and,as arule,with a minimumamountofannoyanceto thoseengagedin themanufactory. Every organin thebodyof an animalmayberegardedas achemicalfactory,and the wasteproduct maybe agas (carbon dioxide),or a fluid(urine),or solidmatter(fa3ces).Thegreatestof all the laboratoriesin the bodies ofvertebrata is theliver,for itreceivesthebloodconveyedto itbytheportalvein,whichischargedwith theproductsofdigestion,such ascarbohydrates,andvariousproteidswhich it obtainsfromthegastro-intestinaltract. Theportalvein is12 DISEASES OF THE BILE-DUCTSalso the channelbywhichmicro-parasites (sucli;isamoeba), echinococcus-embryosandflukes),bacteriaandtheir toxinsfromtheintestines,areconveyedtotheliver.Experimental physiologyhastaughtus that thechief function of the liver is theproductionof apeculiarsubstance termed"glycogen/5whilst bileappearsas a waste or excrementitiousproduct.Assurgeonswe are notparticularlyconcernedwithglycogen, althoughit is a substance of themostprofoundinterest to thephysicianinregardtothe diseaseknown as diabetes;butphysiciansandsurgeonsare oftenconcernedwithirregularitiescon-nected with theescapeof thebile,which takesplace bymeansof an elaboratesystemofpassagesin the recesses of theliver,andconveythe bile fromits source in thehepaticcells to bedischargedintothe duodenum.Alargeamountofingenious histologic investiga-tionhasbeenexpendedwiththehopeofdeterminingtho exact manner in which thebile-passagescomeint.) relation with thehepaticcells:althoughthematter lias notbeenpreciselydetermined,it isquitecertain thattheyarise in the most intimate associa-tion with thehepaticcells,and become obvious tothemicroscopeas minute intercellularpassages (bilecanalicnli),which communicate with the bile-ductsramifyingin the interlobular connective ti---ue. Thebile-ducts around the lobulespossessconnective-THE BILE-DUCTS3tissue walls and are lined with shortcolumnarepithelium,but in theportalcanals the ducts arelargerandthe coatscontain areolar tissue andplainmuscle-fibres;theepitheliumis columnar(Fig. 1).The bile-ductsconvergeto theportal fissure, and,enlargingastheybecomeconfluent,issue as therightandthe lefthepaticductrespectively: theseVeinLymphaticBile-duct-Lymphatic-WArtery-FIG. 1. Transversesectionofaportalcanal.(AfterSchafer.)conjointo formthehepaticductwhich issues fromthe transverse fissure of the liver and receives thecysticductdescendingfrom thegall-bladder;to-gethertheyformthe commonbile-duct whichopensinto the secondpartof the duodenum. Thelargeducts and thegall-bladderconstitute theexcretoryapparatusof the liver and are of suchimportancethat each willrequiredetaileddescription.Theexcretory apparatusoftheliver.This consists4 DISEASES OF THE BILE-DUCTSofthehepaticduct,thecysticduct,thegall-bladder,andthecommonbile-duct(Fig. 2).Thehepaticduct,formedbythe union of theR. hepaticductL.hepaticductSupraduodenalportionofcommonductPiinrreaticportionDuoiU'imlportionAmpullaDuodenumFIG. 2. Adiao;r;ini ir]rr>rnliiii;therelationshipoftheductswhichconstitutetheexcretoryapparatusoftheliver.rightand lefthepatic duct,has anaveragediameterof4mm.,and inlengthvaries from 3 to 5 cm. Itlies in front of theportalvein betweenthe folds ofthegastro-hepaticomentuni.THE BILE-DUCTSCommonbile-ductIG. 3. Thegall-bladderopenedto show thedepressionsin itsmucous membraneandthe valvular folds in thecysticduct.(AfterKehr.)6DISEASES OF THEBILB-DUCTSTin:(jall-binelder. Thegall-bladdeVis ;ipyrii'ormsaclodgedin a fossa on the under surface of therightlobe oftheliver,and holds under normal con-ditions aboutanounceanda half(40 c.c.)of iluid.When distended its fundusprojects beyondtheanteriorborderof theliver,whilst its narrowend orneck is directed towards the transverse fissure. Theunder surface of thegall-bladderis coveredbytin1peritoneumwhich invests the under surface of theliver,andits fundus is coveredcompletelywithperi-toneum. The extent to which thegall-bladderisinvestedbyperitoneumvaries,,and insome instance'sthegreaterpartof it is coveredandtheorgan slungto the undersurface of the liverbyamesentery.Thegall-bladderissupplied bythecystic artery,abranchof therightdivision of thehepaticailcry:thecysticveinsopeninto theportalvein. Itsnervesare derivedfromthe cceliacplexus.Thegall-bladder possessesa muscular and con-nective-tissue coat: the muscularfibres in the mainrun alongitudinalcourse but some have a circularor transverse direction. It is lined with mucousmembrane whichpresentsnumerousdepressionsoralveoli,and on the floor of thelargeralveoli theorifices of mucous recessesmayle seen(Fig. 3).Theepitheliumliningthegall-bladderiscolumnar.Thenarrowportionor neck of thegall-bhulderformsjinS-shapedcurveas itjoinstin-cysticduct(Fig. 5).The termination of thegall-bladderand thebegin-THE BILE-DUCTS 7ningof thecysticductis indicatedbyawell-markedfold or valve of mucousmembrane.Thecysticduct. Thisduct,3 cm.longand23mm.indiameter,intervenesbetweentheneckofthegall-bladderandthehepaticduct. Itisstructu-rallya continuation of the neck of thegall-bladder,and contains valvular folds of mucous membrane(valvesofHeister).Thecystic joinsthehepaticduct at an acuteangle,andtheir confluence marksthebeginningof the commonbile-duct.The common lile-duct(ductuscommunis chole-dochutt).Thecommonbile-duct(practicallya con-tinuation of thehepaticductbeyondthepointofentrance of thecystic duct)is about 7*5 cm.(3 in.)inlength,and5 mm.wide,andpassesbetween thelayersof thegastro-hepaticomentumin front of theportalvein and to therightof thehepatic artery.Itpassesbehindthe firstpartof theduodenum,anddescendingbehindthe secondpartof the duodenumconies into close relation with the head of thepancreastoform ajunctionwith thepancreaticduct.Theconfluent,but notinosculatingductstogetherpiercethe duodenalwall,andafterrunningobliquelythroughits coatsfornearly2cm. andformingalowridgebeneath the mucousmembrane,terminate inanampulla (ordiverticulumofVater).Thecommonbile-duct is anelongated funnel,with its mouth atthejunctionof thecysticandhepaticducts andthenarrowendat theampulla.8 DISEASES OF THE BILE-DUCTSTheampulla.This diverticulum(of Vater)as itis oftencalled,occupiesthebase of apapillasituatedin the mucousmembraneon theposterioraspectofthe secondpartof theduodenum,8 cm. from thepyloricorifice of the stomach. Thispapilla projects!!.. k Tin-aiiipulliiwith the terminuti"ii (!' the commonbile-ductaiidthepancreaticduct.(AfterTuffier.)fromthe duodenalmucousmembrane,andresemblesverymuchthe lacrimal caruncle;it is shelteredbyaneyelid-likevalvula of mucousmembrane(Fig. 4),andopensinto the duodenumbyan orifice about3 mm. in diameter. This terminal orifice is thenarrowestpartof theexcretory apparatus.WhenTHE BILE-DUCTS9distended theampullaisovoid,and about 6 mm.long*and4mm.wide.The chief variations connected with the terminalsection of the duct are these :The common bile-duct and thepancreaticductmayterminateindependently.Thepapillaindicatingtheampullamaybe absentandtheductsopenat thebottomofadepressioninthe mucous membrane. Evenwhenthe ductsopen separatelythepapilla maybepresent, theductsopeningindependentlynearits base.Aninteresting morphologic anomalyconsists inthepancreaticductopeningon thepapillain thenormalposition,but the bile-duct associates itselfwiththe duct of anaccessorypancreas (Santorini's).The relations of the common bile-duct to theadjacent organsare ofgreat practical importanceto thesurgeon. Quenu suggestedthat it is con-venient to divide it fordescriptive purposesandclinical reference into threeportions:(1)Thesupraduodenalportion (3'5cm.).(2)Thepancreatic (or retroduodenal) portion(2-5 cm.).(3)The duodenal(infraduodenal)or terminalportion (1'5 cm.).Thesupraduodenal portionextends from thejunctionof thecysticduct to thepointwhere thecommonductcomes into relation with thepancreas.Thispartlies in thegastro-hepaticomentum and isin relation with the foramen of Winslow. It re-10 DISEASES OF THKBILE-DUCTSpresents nearlyhalf tin- totallengthof tin-duct,and is crossed near itsterminationbyatwigof thepancreatico-fluodenalartery;occasionallythis is alargevessel(Quenu).Thepancreatic portion usually occupiesa tunnelin the head of thepancreas:in some cases it ismerelyagroove.The terminalsegmentlies in the wall of theFia.5. Therelationsofthebile-ducts,portalvein,andhepaticarteryattheportahopatica.duodenum andopensinto theampulla,save in theinstances when this diverticulum isabsent,then itmay openon the free surface of the duodenalmucousmembrane : it is the shortestsegment.It will be seen on reference to thediagram(Fig.2)that thecysticduct with thegall-bladdermayberc^iirtledfrom the anatomicpointof view as adiverticulum from the main bile-duct.hiconsideringtheanatomyof these ducts it isTHE GALL-BLADDER11importantto remember thattheyare imbeddedinareolartissue,which often contains alargeamountoffat,andtheyare in close relationwith the maintrunk of theportalvein and thehepatic artery;numerous small blood-vesselsramifyon the walls oftheducts,as well assympatheticnerve-twigsofsome size derivedfrom the coeliacplexus,includingtheterminaltwigsoftheleftvagusnerve. Thefatin which theseducts, nerves,and blood-vesselsareimbeddedalso contains severallymph-nodes.Abnormalities of thegall-bladder.The chief ofthese are connected withcomplete transpositionofviscera. In this condition the liver liesmainlyinthe lefthypochondrium;the left lobe is thenlargerthan theright,andlodgesthegall-bladder;theduodenum and stomach are also reversed. I havemet withtranspositionof the viscera once in thecourse of 3000 cooliotomiesperformed duringthelasttwenty years.In one case oftranspositionofviscera thepatientsuffered fromgall-stonesandcholecystotomywasperformedonthe left side. Theabnormalarrangementof the viscerawasrecognisedbeforeoperation (Beck).Absenceofthegall-llaelder. It iscurious, seeingthat thisreceptacleisveryinconstant in mammalsandbirds,that it should be so constant inman,forabsence of thegall-bladderis averyrareanomaly.It is absentinthehorse, ass,anddeer : itsvariabilityis wellexpressedamongbirds,formanyof the class12 DISEASES OF THE BILE-DUCTSAves lackit,and evenin the samefamilyas,forexample,theparrotssome memberspossessandothers lack agall-bladder.Thefundus of thegall-bladdermaybebifid,andthis variationmaybe so marked that thegall-bladder has been foundduplicated.In one case eachgall-bladderpossessedaseparatecysticduct;oneopenedintothehepaticduct(Purser).Apartfrom cases oftranspositionof viscera thegall-bladderhas been found on the undersurfaceof the left lobe of the liver(Kehr, Rolleston).Thegall-bladderis sometimes constricted in themiddle and assumes anhour-glass shape.This isnot uncommon when it isoccupied by gall-stones,and theanomalyisprobably rarelyseenindepen-dentlyof chronic calculouscholecystitis.BILE.Thecolour ofhealthyhuman bile in the commonduct as seen in the course of anoperationis abrightgoldenred;after retentionin thegall-bladderit becomesgreen.Thesojournof the bile in thegall-bladderalters itsqualityas well as itscolour,mainly bythe admixture of mucus. The reactionof bile is neutral orfaintlyalkaline.Fostergivestheaverage compositionofbile takenfrom thegall-bladderas :THE BILE 13Waterin 1000parts. . . 859'2Bile-salts . . . 91 '4Fats 9-2Cholesterin 2'6Mucusandpigment. . . 29'8Inorganicsalts . . . . 7*8-140-8Themostmarkedfeatureisthe absenceofproteids.Amongthe solid constituents ofbile,surgeonsareparticularlyinterested in cholesterin and the bile-pigments.Cholesterin(C26HM0)or(C2CH43OH).Thispeculiarsubstance,sometimes called"bile-fat,"a monatomicalcohol,formsthegreater partof mostgall-stones.Insoluble in water and coldalcohol,soluble in hotalcohol, ether,andchloroform,it is dissolvedbythebile-salts(sodium glycocholateandtaurocholate) ,hence it ispresentin solution in bile. Asolutionof cholesterin in chloroformgentlyshaken withanequalamount of concentratedsulphuricacid,turnsred andultimately purple;thesubjacentacidacquiresagreenfluorescence(Salkowski's reaction}.Pigmentsof bile.Thegoldenred of normalhuman bile is due to biliwibin : itmaybeobtainedfromtheurineofjaundicedpersonsas anamorphousorange-coloured powder,or in well-formed rhombictablets andprisms.Insoluble inwater,it isreadilysoluble in chloroformandalkaline fluids.14 DISEASES OF THE BILE-DUCTSWhentreatedwithoxidising agents,such as nitricacidyellowwithnitrousacid,itdisplaysa successionof colours in the order of thespectrum.Thus fromred it becomesgreen,blue,violet,andfinally yellow.This is the basis of the familiar Gmelin's test forbile-pigment.An alkaline solution of bilirubinrxp>sodin a shallow vessel to air becomesgreenfrom conversion into biliverdin. This isprobablythebodywhichgivestobilewhich hasbeenexposedto the action of thegastric juiceits characteristicgreenhue.Functions of the bile.These are few and unim-portant:bile,likeurine,is excrementitious. Bilebeingin themainalkaline,it tends to neutralise theacid contents of the stomach asthey passinto theduodenum.Itrenders,when in sufficientquantity,gastric juiceinert towardsproteids.Bile has aslightsolvent action onfat,and it seems to havegreateremulsive action whenmixedwithpancreaticjuicethan whenactingalone: itprobablyhas someantiseptic property,for when bile is hinderedfromflowinginto the intestine the colonbecomes loadedwithclay-colouredf;eces whichyield veryoffensiveTheopinionthat bile ismerelyexcrementi-tious issupported bytheobservation that the wholeof the bilemay escape throughan external fistulaand tin*person'shealth in noway suiters,thoughtin- fistulapersistsfor severalyears.The secretion anddischargeof bile.The secretionTHE BILE 15of bileappearsto be continuous but notuniform,and thisappliesto itsdischargeinto the duodenum.The rate of secretion is influencedbyfluid,andappearsto riserapidlyafter food. When thestomach isemptythe bilepasses alongthehepaticductandenters thecysticduct,to be stored in thegall-bladder. During fastingthegall-bladderfills.When the contents of the stomach enter the duo-denumandrunoverthe bilepapilla,bilegushesout:this rush is due to the contraction of the muscularwalls of thegall-bladder accompanied byarelaxationof thesphincterat the orifice of the commonduct :after thegall-bladderhasdischargedits contentsfora time the bile from the liver runs a direct coursefrom thehepatic throughthe common duct to theduodenum. Whenthedigestiveexcitement subsidesbilemay dripinto theduodenum,but the maincurrent runsthroughthecysticduct to thegall-bladder. About a litre(1*76 pints)is secreted intwenty-fourhours.Thepressureunderwhichbile is secretedis lowerthan the arterialpressure: thismaybe attributedtothe fact that it is secreted fromthevenous blood intheportal system,so it isprobablethat thepressureexertedbythe secretion ishigherthan that in theblood-vesselsfeedingthesecretingcells. Whenfromanycause,such asgall-stones,tumours,stric-ture, etc.,themain duct isobstructed,thepressurein thebile-ducts will rise untilresorptiontakesplace,16 DISEASES OF THE BILE-DUCTSand the bile finds itswayinto theblood, causingjaundice.The bile under suchpressurefinds itswayinto theportal lymphaticsand is carried intothe thoracic duct and thence enters the blood-stream.When carminegelatineisinjectedinto the bile-ducts at apressurenotexceedingthe maximumpressureof thebile,theinjectedmaterialappearsinthelymphaticsof the liver. The bileprobablyescapes throughthe intra-cellularplasmaticcellsdescribedby Schafer,and these channelsmayberegardedasanintermediatesystemlinkingtheblood-vessels of the liver with thelymphaticsat theperipheryof the lobules(HerringandSimpson).REFERENCES.Beck, C.,"A Case ofTransposedViscera,withCholelithiasis,relieved by aLeft-sidedCholecystotomy."AnnalsofSurgery,1899,xxix,p.593.Herring,P.T.,andSimpson, 8.,"ThePressureofBile-secretionandtheMechanismofBile-absorptionin Obstruction of theBile-duct." Proc.Roy. 8oc., 1907,SeriesB,Ixxix,p.517.Purser,J.M.,"Case of a Liver with two Gall-bladders."-Trnns.Acad.Med.,Ireland, 1887, v,p.243.Quenu,"Notesurl'AnatomiedueCholedoque,&un Point devueChirurgical."RevuedeChirurgie, 1895,xv,p.r.t.s.CHAPTER IITYPHOID INFECTION OF THE GALL-BLADDERTHEliver,inadditiontoitsglycogenicfunction, mayboregardedas agreatorganicfilter,whichseparatesnotonlytoxins fromthe bloodconveyedto itbytheportal vein,but alsomicro-organismswhichentertheportalcirculation from thegastro-intestinaltract.Theelimination ofmicro-organismsbythe liver iscapableofexperimental proof.Welch(1891)foundthat when a culture of thetyphoidbacillus wasin-jectedinto the venous circulation of arabbit,thebacilliappearedin the bile fivedayslater. Thebacilli have been found in the bile of a rabbit oneundredandtwenty-eight daysafter anintra-venousjection.These results have been confirmedbysubsequent investigators (LemierreandAbrami).Pathogenicmicro-organismsconveyed bytheportalirculation into theliveraredischargedwiththebile,butin theprocessof eliminationtheyinfect the bile-ductsandespeciallythegall-bladder.Ulceration of the mucous membrane of thegall-K)ladderunaccompaniedbygall-stonesas acomplica-:18DISEASES OF THE BILE-DUCTStionof,andasequelto,typhoidfeverhas beenlongrecognised.Murchison(1862)drew attention totheoccurrence of fatalperitonitisinthecourseoftyphoidfever,setupbytheperforationof atyphoidulcerinthegall-bladder.Themuseumof the MiddlesexHospitalcontains agall-bladder (obtained by Voelcker)in which themucousmembrane is ulcerated in severalplaces,andone of the ulcers hasperforatedthe whole thicknessof the wall of thegall-bladderandits baseis formedbythe liver. It wasobtained from aman,whodiedinconsequenceof theperforationof atyphoidulcerin the lowerpartof the ileuin. Thecolonandileumwereextensivelyulcerated.In some instances the aid ofsurgeryhas beeninvoked for the relief ofpatientswhen an nicer inthegall-bladderhasperforatedin the course oftyphoidfever.Monier-Williams and Sheild in 1895reportedasuccessful case of this kind in a womanjigcd31.Theoperationwas undertake]! under the idea thatan ulcer of the intestine hadperforated,but in thecourseof theoperationthe trouble wa^ traced to thegall-bladder.Dr. Ashhurstoperatedon aboy, aged 12,onaccount ofsymptoms indicatingperforationof atyphoidulcer of the intestine. He failed to find aperforationanddrained the abdominalcavity.Theboydied: at theautopsyevidence ofgeneralTYPHOID INFECTION 19peritonitisandperforationof thegall-bladderwerefound. Hewasmorefortunatewithanotherpatient,ayouth, aged20. In this instance there weresymptomsofperforationin the course oftyphoidfever. Anoperationwasperformed,and a holemeasuring Ifby1^incheswas foundin the wall ofthegall-bladder. Fortunatelythisorganwas buriedindeepadhesions between the liver and colon.Cholecystectomywasperformedand theyouthmadean uneventfulrecovery.Thepus yielded typhoidbacilliinpureculture. Dr. Ashhurst collected therecords, of 19operations performedon thegall-bladderduringtyphoidfever. Of thesetwenty-oneoperations performedonpatientswhilstsufferingfromtyphoidfever,in fourtheoperationwasaban-donedbefore thegall-bladderlesion was discovered.Thesedied. Oftheremainingseventeen,ninepatientsdied andeightrecovered: agratifyingmeasure ofsuccesswhenthegravityof the condition isproperlyconsidered.Thepresenceof thetyphoidbacillus in bileassumed a newimportancewhenKayser,in1906,showedthat after anattack oftyphoidfever thebacillimay persistin thegall-bladder,and travelwith the bile into thealimentarycanal toescapewith the freces.Typhoidbacillidischargedinthiswayretain theirpathogenic properties.Anindividual with agall-bladder harbouring typhoidbacilli in thiswayis knownas"atyphoid-carrier,"20 DISEASES OF THE BILE-DUCTSfor the bacillithey spreadabout arecapableofproducinglocalepidemicsoftyphoidfever.TheStrassburgfemalebakerobservedby Kayserhad hadtyphoidfevertenyears previously, yetherfaeces containedtyphoidbacilli inlargenumbers.Whenthiswomandiedthegall-bladdercontaineda calculus the size of two beans.Typhoidbacilliwere found in cultures from hergall-bladder,andin thegall-stone,as well as in thebile,thespleen,and liver. Shediedfromtyphoid sepsis.This matter has beeninvestigated byDrs. A.LedinghamandJ. C. Gr.Ledingham,andtheycon-firmed theGerman observersand added a series ofvaluable cases worked out withgreatcare andthoroughness.The inmates of lunaticasylumsfurnishedalargeproportionof the cases. Thestudyoftyphoidcarriers has led to a newconceptionofthepathologyoftyphoidfever,and the facts havebeenadmirablysummarisedbyDean in acommuni-cationbased ontheinvestigationof amanwhohadprobablybeenatyphoidcarrierfortwenty-nineyears.Itwasformerlybelieved that thetyphoidbacillusafter itsconveyanceinto thealimentaryranalmultipliedthere,invadedthelymphoidtissue of thesmall intestine andspleen,andfairlylate in thedisrsise found itswayinto the blood-stremn.The newconception,which we owechieflytoForster,maintains that thebacilli arepresentin thebloodduringthe incubationperiod,andappearintheTYPHOID INFECTION 21faecesduringthefirstandsecondweekof thedisease.Thebacilli, therefore,do notmultiplyin thegut.At avery early stagethe bacilli find theirwayinto the liver andbile,andtheirpresence givesrisetoinflammatorychangesin the bile-ducts andgall-bladder.AccordingtoForster,normalbile is not averysuitable medium for thetyphoid bacillus,butwhen albuminousmaterial is addedto it the bacillusfinds it an excellentpabulum.Intyphoidfeverthe albuminous material issupplied bythe in-flammatoryexudatefromtheductsandgall-bladder:the bacilligrowfreelyunderthese conditions in thegall-bladder,andpassoutthroughthe bile-ductintothe small intestine andare thrownout in the faeces.In most casesrecoveryisaccompaniedbyacessa-tion of theinflammatory processin theliver,itsducts,and thegall-bladder;in a certainnumberofcases(2 per cent.)thischolecystitis typhosa becomesa chronicprocess,andpatientsso affected constitutethegroupoftyphoid-carriers.Thechain of evidence iscompletethatthetyphoidbacillus has a remarkablepredilectionfor thegall-bladder,andthatitmayflourishthereinforeight,ten,seventeen,andeventhirty years,andlargenumbersof the bacillimay passalmostdailywith the bileinto thealimentarycanalduringtheselongperiodsand the infectedpersonssuffer no inconvenience.Thereis, however,evidence thattheyare sources ofinfection to otherpersonswholiveinthesamehouse.22 DISEASES OF THE BILE-DUCTSIt hasbeensuggestedas aprophylacticmeasure,thatgall-bladders,wherein thetyphoidbacillus isknown to lead asaprophyticexistence,should bedrained.Dehler(1907)hasperformedcholecystotomyanddrainageof thegall-bladderin twoasylumtyphoidcarriers, thoughneither of thepatients pre-sentedsymptomsofgall-bladderdisease.The relation of thetyphoidbacillus to chole-lithiasis is discussed inChap.V.REFERENCES.Ashhurst,A. P.C.,"Perforation of the Gall-bl .iddi'vduringTyphoidFever." AmericanJournalofMedicalSciences, 1908,i,p.511.Dean,G.,"ATyphoid CarrierofTwentynineYears'Standing-."Brit.Med.Journ.,1908, i,p.562.Dehler,"ZurBehandlungtierTyphus bazillontrager."-Miinch.med.Wochenschr.,1907,No.10,u. No.43.Ledingham,A.,andLedingham,J. C.G.,"TyphoidCarri.-r,"withMiblio^raphy19OUand1907. Ji,-'if. M'.:>os.Yoelcker,A.F.,"Ulceration of tin? (Jail-bladder inTyphoidJ'Vvrr." 7V.//H. /',i//(. 8oe.tiS'.l.",, xlvi,p.7'.).Welch,Professor,"AdditionalNoteconcernini;-Hi" In!ra -vcimusInoculation of tin- /;.I.-;//KSl>i t,J,i uh.lnniin.iHs." Bulletin,/'./../insUnjoin* Hotjnt-il.isiM, xi,p.121.CHAPTER IIIINFECTIONSOF THEBILE-DUCTSANDGALL-BLADDER(CHOLANGITISAND CHOLE-CYSTITIS)Cholangitis.It wasformerly taughtthat inflam-matoryconditions of the bile-ducts are innearlyallinstances due to infection from thegastro-intestinaltract. Moderninvestigationsteach thatalthoughthe essential cause ofcholangitisis invasion of thebile-ductsby pathogenic micro-organisms,theseinfecting agentsare derived from theblood,eitherfromthegeneralor theportalcirculation.Infectionbythe blood-stream hasbeenespeciallystudied in connection withtyphoidfever(seeChap. II).The effects of infectivemicro-organismson thebile-ductsdependin alargemeasure on theirvirulence,on certainfavouringconditions in theexcretoryducts of theliver,andespeciallyon thepresenceofgall-stones.It will be convenient toconsiderthesechangesunderthefollowingheadings.(1)Subacutecholangitis; (2)acutecholangitis;24 DISEASES OF THE BILE-DUCTS(3) suppurative cholangitis;(4)tuberculous cholan-gitis.(1)Sulacutecholangitis.Thisis the mildestformofcholangitis,andis knowntophysiciansas catarrhaljaundice.Thebelief thatit iscausedbytheimplica-tion of thepapillaand common bile-duct in a mildinfection ofthemucousmembrane of the duodenumrestsonnopathologicalbase. Moderninvestigationsteach that infection of the main bile-ducts is withgreater probabilitycauseddirectly bybacteria,ortheirtoxins,in the bile which flowsalongthem(descendinginfections).Thebileobtainsthesepatho-genic agentseither from theportalor thesystemicsystems,as described in thepreceding chapter.Jaundice sometimes arisesindependentlyof ob-struction in the 111:1inexcretoryducts,as acomplica-tion ofgeneral septic infection,but the bile swarmswithstreptococcior similarpathogenicorganisms.(2)Acutecholangitis.In this disease thelargeducts are involved and the infectionimplicatesthemucousmembraneof thegall-bladder (cholecystitis).In somecases,especiallythose associated withgall-stones,theintra-hepaticducts arc infected withverydirefulconsequences (see Chap. VII).It will l>e convenient to discuss the effects ofcholangitiflaccordingto theportionof theexcretoryapparatus chieflyinvolved in the infection.Manyof thecim-equencesare ofgreatpathologicalandclinical intere-t.CHOLANGITIS 25Anacutecholangitisof thelargeductsmaysub-side and leave notrace,or itmaybecome chronicandlead tochangesinthewallsoftheducts,thicken-ingthem, causing desquamationof theepitheliumoractual ulceration. Suchchangesnotonlylead tothickeningof the wallsof theducts,but the inflam-matoryproductswillultimately organiseintofibroustissue and the duct becomes converted into an im-perviouscord. Thisobliterating processis some-times described assclerosis,and it occurs in its mostfamilar form in the maleurethra,as asequelofchronic(infective)urethritis.Thischange certainlyoccurs in the bile-ductsand in thegall-bladder,for all these structuresmaysometimesbe found reducedto witheredcords,andoccasionallythe obliterativeprocessis socompletethat it isextremelydifficult todistinguishtheminthe course of anoperation,or evenbydissectionafter death.This slow fibrous conversion of the main bile-ductinto animperviouscord isveryserious,for itmaylead to death.Sidney Phillipshaspublishedanexampleand collected somerecorded cases whereastricture of thecommon,or thehepaticduct hascaused intractablejaundice, ending fatallywithoutanyhistoryofcolic,vomiting,oranything pointingto thepassageorimpactionofgall-stones.Hispatientwasamanagedsixty years,andan ulcer aslargeas ashillingexisted at the lesser curvature of26 DISEASES OF THE BILE-DUCTSthestomachontheposteriorwallthreeinches fromthepylorus.Thegall-bladderwasdistended to the si/eof averylargepearand filled withcolourless mucus,In reference to this condition Murchison(1868),writingon"stricture or obliteration ofthecommonbile-duct,"states that agall-stoneaftercausingoleerationmayescape,anda stricture formduringtlic ci'-atrisation of theulcer,ami thatoccasionallyulceration of thebile-duct,withsubsequentcicatri-sation,appearsto beindependentofgall-stones,andstatesthatulceration of thebiliarypassages,in-dependentofgall-stones,isoccasionallyfound afterdeath from enteric fever. It is also certain thatstricture of the common bile-duct occurs inde-pendentlyof bothcauses,forit isoccasionallyfoundin new-bornchildren,and in some of these littlepatientsit obliterates the mainexcretoryconduitsofthe liver in antenatal life far moreextensivelythaninanyotherperiod (see Chap. IV).Amongthe few recorded cases of stricture of themain bile-duct theexamplerecordedbyM\-nn isthe mustremarkable,for in hispatientthe"hepaticduct at thejunctionof the two divisions was swollenfrom thepresencein it of atoughmatter,makingalittle softknot of the si/e of an almond aroundandin its walls. Thelengthof the stricture was oneinch,and its causesimpleconnective tissue in theform of ascar,the stateresemblingthat seen inordinary simplestricture of the urethra."CHOLANGITIS 27It isnoteworthythatnearlyall the writersmake thecomparisonwith a urethralstricture,anddefinitelystate the dilated ductsbehindthe stricturecontainmucus. In a case recordedbyBristowe thestricture occurredin the lefthepaticduct.There is asuspicionin the minds of some writers(andwhich I consider is wellfounded)that some ofthe casesreportedas fibrous stricture of thehepaticand common ductsmayhave beenexamplesofprimarycancer(See Chap. X).Completeobliteration ofthecysticduct iscommon,and,as arule,due to traumatism fromgall-stones,andthegall-bladderbecomes alargeretentioncystormucoceleinconsequence;obliteration of this ductalso occursapartfromgall-stones,andfromthe samecause that leads topartialobliteration ofthecommonandhepaticducts in adults. In rare instances asyphiliticlesion of the livermayinvolve andobstruct the common duct(Lazarus-Barlow).(3) Suppiirative cholangitis.Whenthebile-ductsare infectedbya virulentpus-producingmicro-organism,thechangeswhichresult are akin to thoseproducedin similar circumstances in other mucouscanals. The mucous membranes of the ducts areswollen withinflammatory exudation,and theirlamina become blocked with shedepitheliumandpusstained with bile : the ducts themselves fill withpus,and inverysevere conditions theintrahepaticducts becomepus-containingcanals dilated at28 DISEASES OF THE BILE-DUCTSintervals intolargercollections ofpusorabscesses.Occasionallysomeof these collections ofpusbecomeconfluent and form a liver abscess oflargesize.Theliver isalways enlargedinsuppurativecholan-gitis,and thelymph-glandsin theportalfissurebecome infected and increase in size.The infection sometimes extends to theportalvein,whichmaybecomethrombosed(pylephlebitis),or even filled withpurulentclot(suppurative pyle-phlebitis).Theperitoneum coveringthe liver becomes im-plicatedin the inflammation, and thismaylead tofatalperitonitis. Occasionallyfatalperitonitisisdue to theburstingof an abscess which hasmadeitswayto the surface of the liver. Thissequelisconsidered in connection with calculouscholangitis(Chap. VII).(4)Tuberculouscliolangitis.Tubercle bacilli de-rived from tuberculous foci in the intestines areconveyedtothe liverbytheportalveinandproducemiliarytubercles in theportal spaces.Thesegiverise to masses ofgranulation-tissuewhichsoften,Invnkdown,anddischargeintoaneighbouringduct,andgiverise to an extensive infection of the ducts(tuberculous cholangitis).Eventhoughthe ductsan-extensivelyinvolved,there is nojaundice.As arule thedisease occursas asequelofpulmonaryandintestinaltuberculosis,and itssubjectsaregenerallychildren. The disease has nospecial symptoma-CHOLECYSTITIS 29tology,and does not come within thescopeofsurgery.Acareful account of tuberculouscholangitis,withsome excellent illustrations and references to theliterature,isfurnishedbyH.MorleyFletcher. Ser-jent,Gilbert,andClaudehavepublishedevidence ofanexperimentalkindwhichsupportstheviewthattuberculouscholangitis maybe due to microbicinvasion of the ductsfrom the blood-stream.Tuberculous disease of the duodenummayextendinto the commonbile-duct,cystic duct,andgall-bladder. Lancereaux has described such a con-dition in awomanagedthirty-two years.Cholecystitis (inflammationof thegall-bladder).Cholecystitismaybepartandparcelof ageneralinfection of the bile-ductsystemof the liver;itis,however,necessaryto consideritseparately,notonlyon account oftheimportantconsequencessometimesassociated withit,butmoreespeciallyin its relationto the formation ofgall-stones.From the anatomicalpointof view thegall-bladderis a diverticulum from the mainbile-duct,andpathological processesoftenproceedin an in-sidious andunsuspecting wayin thisreceptaclewithout inanywayinterferingwiththe flow of bilealongthecommonduct,until,withoutanywarningindeed,often withthe suddenness of anexplosionseverechangesoccur in connection with it whichplacethepatient'slife in thegravest possible30DISEASES OF THE BILE-DUCTSperiland notinfreqentlyterminate it in a fewdays.It isnecessarytopointout that the infection ofthegall-bladderin the first instanceformedpartofageneralinfection of theexcretory apparatus,butthefree communionof the common duct with the duo-denum affords it aneasy drainage-trackwhich isdeniedthegall-bladder.Ifthecysticductisblockedbyswollen mucous membrane orgall-stones,andwhilst the mainducts return to afairlynormalstate,theinfection,thoughlargelydeprivedofitsvirulence,retains a certain amount ofpotencyin thegall-bladder, or,toexpressit in clinicalterms,remainschronic. Thisaspectof the matter will bo morefullyconsidered in connection withgall-stones.The occurrence ofcholecystitisas asequeltogeneral septicinfection of theexcretory apparatusof the liver is like chronicsalpingitifi persistingafter the acutesepticendometritis which establishedit has subsided.An infectedgall-bladder may suppurate,ulcerateorslough: its wallsmaycalcifyorundergosclerosis,liarelyit is attackedby actinuinycosisand tuber-culosis.(]) Cholecystiti*.Thismayformpartof ageneralmild infection of the wholeexcretoryapparatus,or be a residue of an acute infection;it is avery importantalTection because carefulinvestigationshave established the fact that one ofCHOLECYSTITIS 31the chiefconsequencesof subacute and chroniccholecystitisis toproducechangesin theepithelialelements of thegall-bladderwhich lead to thepro-duction of an excessivequantityof cholesterin andto the formation ofgall-stones (see Chap. V).Itis on this accountthatnearlyall the serious diseaseswhich affect thegall-bladder, includingcancer,arecomplicatedwithgall-stones.Intruth,the milderforms ofcholecystitis maybe called thegall-stone-formingdisease.Whentheinflammatory changesare sufficient toocclude or obliterate thecystic duct,the accumula-tion of mucus secretedbytheglandsin themucousmembrane will distend thegall-bladderandform amucocele;gall-stones mayormaynot bepresent.Agall-bladderdistended in thiswayis sometimestermedTiy dropsvesicsefellvse:occasionallythe in-flammatory changes maybesufficientlysevere todestroytheepitheliumand thicken its walls in thewaydescribedin connectionwithcholangitis,andthegall-bladderwill becomereducedtoathinimperviousbandof fibrous tissue.(2) Suppurative cholecystitis.Notinfrequentlywhengall-stonesarepresentpathogenicmicro-organ-ismsgainaccess to thegall-bladderand establishsuppuration.Thepresenceof calculi in thegall-bladder isapredisposingfactorinacutecholecystitis.Inthese circumstances thegall-bladderbecomesdistended withpus,a condition often termed em-32 DISEASES OF THE BILE-DUCTSpyemaof thegall-bladder.It ispreferabletorestrict this term to acollection ofpusin thepleuraandspeakof thispurulentcondition of thegall-bladderassuppurative cholecystitis.In severesepticinfection ofthegall-bladder its wallsmaybecomegangrenousandslough.This is calledphlegmonous or, better,gangrenous cholecystitis.Thegall-bladder,like an ovariancystor ahydronephrotic cyst,willoccasionally implicateanadjacentcoil ofbowel,and thepartsin contactmaybecomethinenoughto allow of the osmosis ofintestinal fluid withmicro-organismswhich will setup suppuration.Theappearanceof thegall-bladderwhenacutelyinflamed differsaccordingto the virulence of theinfecting micro-organism.In itsordinaryconditionthegall-bladderhas thinwalls,but whendistendedwith mucus in the conditioncommonlycalled"hydrops"the fluid it contains issterile;the wallsmaybe very thinandtranslucent,butinacuteinfectivecholecystitisdue to such microbes as the Bacilluscolit streptococcus,or thepneiimococcus,its wallsbecomethick,oedematous,andlividorplum-coloured,sometimesgreen andoccasionallyblack(gangrenous).Thesechangesare similar to those seen in sectionsofintestinewheninfectedsecondarilytostrangulationin a hernial sac or avolvulus.Acuteinfective conditionsariseinthegall-bladderwith the same suddenness as an acute(fulminating)CHOLECYSTITIS33appendicitis,or intestinalobstruction,and often inpatientswhoafew hourspreviously appearedto beFIG.6. Aninvertedgall-bladder.,theseat of acutecholecystitis,showingulcersin themucousmembrane, oneof whichperforatedintothegeneralperitonealcavity.in their normal condition of health. Death in. thesecircumstances is causedbyinfectiveperitonitis,duetoperforationof the wall of thegall-bladder,which334DISEASES OF THE BILE-DUCTSallows the infective material toescapeinto thegeneralperitoneal cavity (Fig. G).(3)Ulc-erativecholecystitis.Theonly specificinfection of thegall-bladderto which theadjective"ulcerative"strictly appliesis that due to thetyphoidbacillus(see Chap. II).Cholecystitisassociated withgall-stonesis oftencomplicatedbyulceration of the mucousmembnim-,andsome of the mostdangerous consequencesarisingfromgall-stonesarebroughtaboutbytheulceration;for it leads toperforationof thewallsofthegall-bladder,and it will involveadjacenthollowviscera,leadingto events whichmaytenmiiiih- inaluckymanner for thepatients,but,on the otherhand,oftenplacetheir lives in thegreatest peril.(4)Gangrenous cholecystitis.The destructiveeffects of acutecholecystitisare illustratedbythespecimen Fig.7;in this instance the whole of themucousmembrane was foundlyingas asloughinthegall-bladder.There weretwoperforationsinthewall of thegall-bladder,oneopeninginto the trans-verse colon andthe other intothegeneral peritonealcavity.Themanwasfifty-eight yearsofage,andhe died in the MiddlesexHospitalafter an illnessof tendays.Thepancreascontained several sm;illabscesses.(5)Membranouscholecystitis.Thistermisappliedto anacute andusuallycalculouscholecystitisinwhich a membrane forms on the inner surface ofCHOLECYSTITIS 35thegall-bladder.This membranemaybepresentinpatches,or itmaybe so extensive as toproduceacompletecast of thegall-bladder.Caseshavebeenreportedinwhichsuch membranesFIG. 7. The mucous membrane of agall-bladderwhich hadcompletely sloughed;it isrepresentedinverted with theminute calculi dotted over it.lavebeenshedinpatchesormoreorlessentire,andtheirpassage throughthe ducts wasaccompaniedbyattacks ofpain (biliary colic)and themembranehasbeenrecognisedin the faeces.I have removed a calculousgall-bladderwith36 DISEASES OF THE BILE-DUCTSsuccess from awomanaged seventy-six yearsonaccount ofgangrenous cholecystitis;patchesofmembrane like thatseen indiphtheriawerepresenton its mucousmembrane.Calcification of thegall-bladder. Manymuseumscontainexamplesof calcifiedgall-bladders.It israre to find the whole of theorgan calcified,but inmanyexamplestheprocessisveryextensive,andthegall-bladderlooks like adamagedegg-shell.Thiscondition isprobablyasequelof chronic orsubacutecholecystitis.It is well to bear in mindthat echinococcuscystsin the liver aru liable tocalcify,andinthe course of anoperationitmightbesomewhatembarrassingtomeetwith a calcifiedgall-bladder.Sclerosisof thegall-bladder (cholecystitisobliterans).Asaconsequenceoflong-continuedinflammationthe walls of thegall-bladderthicken andslowlyundergoconversion(ormetaplasia)intofibroustissue,and if free from calculitheywill,in the course ofyears,bereduced to the condition of a mere fibrouscord,andcanonlyberecognised byits situation inthe fossa for thegall-bladder.Actinomycosisof thegall-bladder.Theonlyexampleof this diseaseatpresentrecordedis a casedescribedby MayoRobson. Thepatientwas aman,agedforty-seven years,whocame under observation withthe usualsymptomsof cholecystitis. At tin-opera-tion alarge gall-bladderwas found adherent to theANEURYSM OF HEPATIC ARTERY 37abdominalwall,to theliver,andthe omentum;allthesepartswereintimatelyadherent and invadedwithgranulation-tissue.This morbid tissue wasthoroughly scrapedout,and in thelaboratoryfurnished themicroscopicfeatures ofactinomycosis.Thepatientwas treated with iodide ofpotassium,and threeyearslater his condition of healthwasreportedto besatisfactory.Theroute of infectionwasnot determined.Tuberculouscholecystitis.Tuberculouscholecystitisis a rare disease;itmaybe localised to thegall-bladderor occur in association with tuberculosis inotherpartsof the abdomen. Korte met with anexample,andfurnishes adrawingofthegall-bladderandreferences to six other cases which have beendescribed.Simmonds haspublishedsome observations onthiscondition,andcomesto the conclusion that it isan"excretiontuberculosis,"andthat the bile-ductsandgall-bladderare infectedbytubercle bacillicontained in thebile,justas tuberculous infectionof the renalpelvis maybe inducedbybacilliexcretedwiththe urine.Aneurysmof thehepatic artery.Thisartery,incommon with thosesupplying viscera,is liable tobecome the seat of ananeurysm,sometimes fromembolism andveryrarelyas a result ofinjury;itisalsoprobablethat someaneurysmsof thehepaticarteryor its branchesmaybe due to ulceration38 DISEASES OF THE BILE-DUCTSstartingin the walls of thegall-bladderor thebile-ducts anderodingthe wall of the-artery(Rolleston),andrarelythe uleerationmaybe duetogall-stones.Thatulcerativecholecystitis mayproduceanextra-hepaticaneurysmof thehepatic arteryis of interestin connection with an observation ofKehr,whooperatedon a case(andwithsuccess)in which ananeurysmof thisarteryopenedinto thegall-bladder,Riedel encounteredin the course of anoperationananeurysmof thisarteryasbigas anapplewhichopenedinto thecysticduct. Otherexampleshavebeenrecorded,and Kelir madehis case the basis ofaninterestingandvaluablepaper.In an instance recordedbyRoss ananeurysmofthehepatic arterybecamesepticand emboliweredistributed in theliver,givingrise tomultipleabscesses.Anintra-hepatic aneurysm maybe the cause ofpuzzling symptoms.In one recorded instance aman,forty-five yearsofage,had attacks of severeiKematemesis,andlie diedinCharingCrossHospital;at thepost-mortemexamination an abscess aslargeasanorangewasfoundprojectingfrom the under-surl'ace of theliver;its walls were in onepartadherentto,and itscavitycommunicatedwith,theinterior of the stomach. Ananeurysmaslargeasanalmond was found on a branch of the lefthepaticartery;it had burst into thecavityof the ab-ANEtJBYSM OF HEPATIC ARTERY 39andthe bloodhadleakedthroughtheperforationintothe stomach and wasvomited. Inreportingthiscase Pearson Irvine states that the relation of theaneurysmto the abscess was similar to ananeurysmof thepulmonary artery projectinginto a vomica.Mnrchisonsuggestedthat the freebleedingwhichoftenaccompaniestheopeningof an abscess in thelivermay occasionallybe due to anintra-hepaticaneurysm.Ananeurysmof theextra-hepatic partof thehepatic arterycausessymptomsof such a definitecharacter that itsdiagnosis mayin some cases be aclinicalpossibility,althoughthesymptomsaresimilarto those of ananeurysmof thesuperiormesentericartery.In 1861 Frerichs summarisedthesymptomsof ananeurysmof thehepatic artery: There is atumourwhich is sometimesremarkably largeanddisplacestheliver;neuralgicpainfrompressureonthehepaticplexusof nerves;andjaundicefrompressureonthebile- ducts. The fatal termination is most casestakesplacewithsymptomsof internalhaemorrhage.It isvery easyto mistake such a case for the colicarisingfromgall-stones.REFERENCES.Bristowe,J.S.,"Obstruction of the CommonDuctbya Cal-culus; Dilatation, Suppuration,and Destraction ofHepaticDucts;Communication with Branches of Portal Vein andLung."Path. Soc.Trans., 1858, ix,p.285.40 DISEASES OF THE BILE-DUCTSFletcher,H.Morley,"Tuberculous Cavities in the Liver."Path. Soc.Trans., 1899, 1,p.Kin.Gilbert, A.,andClaude,H.,"TuberculoseExperimental*;dufoiepar1'ArterieHepatique." ComptesRendus Soc. deBiologie,1896,tenthseries, iii,p.483.Irvine,Pearson,"AneurysmoftheHepaticArteryintheCavityofanAbscessoftheLiver;Perforation of theStomach,andRuptureof theAneurysminto it." Path.Soc.Trans.,1878,xxix,p.128.Kehr,Prof.H.,"DerersteFall vonErfolgreichenUnterbindungder Art.Hepatica PropriawegenAneurysma."Miinch.med.Wochenschr., 1903,L. 1861.Korte,Prof. W.BeitrugczurChirnrgiederGallenwegeund derLeber,Berlin,1905.Lazarus-Barlow,W.S., "SyphiliticStricture of Bile-ducts."Path. Soc.Trans., 1899, 1,p.158.Moxon, W.,"SimpleStricture of theHepaticDuctcausingChronicJaundiceandXanthelasma." Path.Soc.Trans.,]s7::.xxiv,p.ll"..Phillips, S.,"ACase of Strictureof theBile-duct." Clin. Soc.Trans., 1888, xxi,p.26.Robson, A. W.Mayo,"Actinomycosisof the Gall-Bladder."Meiliro-Chii-n.i-'j. Traiu.,I'.xir,,Ixxxviii,p.225.Serjent, E.,"La Tuberculose des Voies Biliaires."ComptesRendusSoc. deBiologie,IH'.MJ. tenthseries, ii,p.336.Simmonds, M.,"Ueber (Jallenblasen tuherculose." Centralb.f.Ally.Path.Anat.,1908.CHAPTERIVCONGENITAL OBLITERATIONOF THE EX-CRETORYAPPARATUSOFTHELIVERTHIS is a rareanomalyandconsists,as thenameindicates,in the obliteration of the mainexcretoryducts of the liver and sometimes thegall-bladder.The diseaseoriginatesin late foetallife,and isaccompanied bycirrhosis of the liver andjaundice.In 1892 Dr. John Thomson tabulatedforty-ninerecorded cases of thedisease,and Rolleston hasaddedtwelvemore(1903).There is no definitepartof theexcretory appa-ratus to which the obliterativeprocesslimitsitself,and the manner in which theobliterating processpicksout variouspartsis remarkable. It is morefrequentin thecommonductthan elsewhere.In aspecimen preservedin the museum of theRoyal CollegeofSurgeonsthe terminal twoinchesof thecommonduct arerepresentedbyafineimper-vious fibrousthread,butthepapillainthe duodenumis normal and a thin bristle canbepassedinto thepancreaticduct.42 DISEASES OF THE BILE-DUCTSThemuseumof St.Mary'sHospital,London,con-tains aspecimenin which the externalexcretoryapparatusof the liver isrepresentedbysolid cords.The museum of the WestminsterHospital possessesan infant's liver in whichthehepaticandcommonbile-ductsappearas solidcords,and thegall-bladderisrepresented merely bysome loose connectivetissue.In contrast to this extensive obliteration of themainducts it is curious to finddescriptionsofspeci-mens in which theprocesslimits itself to theverytermination of the commonduct,the duct behindthe obstructionbecomingdistended into acystcontaining36 oz. of bile(Oxley).In someexamplesthe duct is obliteratedupto andincludingitstermination,but thebile-papillaispreserved.A(-ireful consideration of thereportedcases serves toshowthatwhentheobliterating processis limited toa smallportionof the terminalsegmentof thecommonduct,thepartabove the stricture isapttodilate andbecome alarge cyst(Fig. 9).Frerichs refers to observationsrelatingto thiscondition in infants asearlyas17'J-".,and mentionsparticularlyanexampledissectedbyAbrahamYater.Associated withcongenitalobliteration of the bile-duct isenlargementof theliver,with cirrhoticchangesin its tissue. Inmanyinstances thespleenis alsoenlarged.Insomeinstancesseveralexamplesof thisanomalyhave occurred in the samefamily.OBLITERATION OF BILE-DUCTS 43Emanuelhas describedwithgreatcareaspecimenofcongenitalobliteration of the bile-ducts in whichthere was fibrosis of thepancreasand of thespleen.In thisinstance,thoughthepancreaswas in theprocessofbecomingfibrosed,itsmainductswerewellformed andopenedin the usualwayinto theduodenum.The chiefsignsof the disease aredeep jaundice,haemorrhages,withenlargementof the liver andspleenininfancy. Manyof the-children die withinafewdaysofbirth,butsomehave survived for sixmonths. The usual cause of death ishemorrhagefrom mucoussurfaces,such asstomach, intestine,nose,orfromthe umbilicus.Concerningthecauseoftheconditionthereismuchspeculation.Intheearlywritingsonthisdiseasetheprimaryfactorwasbelievedtobeacongenitalmalfor-mationoftheducts,andthebiliarycirrhosiswassecon-darytotheirobliteration.Now,theprevailingopinionregardstheprocessasindependentofanycongenitalmalformation,andattributes it to toxicbodies in thebile, causingadescending cholangitis.Rolleston has described aspecimenofcongenitalobstruction of the commonbile-duct,which heattributed tosyphilis.Healsopointsoutthatsomeof thereportedcases of stricture of the commonbile-duct inearlylifemaybe a later result ofthisprocess.The value of this observation lies inthesupportitgivesto theopinion,that several44DISEASES OF THE BILE-DUCTSdifferent conditionsmaycauseobstructionoroblitera-tion ofthe-excretoryapparatusof the liver in new-bornchildren.Mostof thosewho have considered thisanomalyhave devoted their attentionmainlyto theducts,withoutconsideringitinrelationtootherexamplesofante-natal obliteration of theexcretoryducts.Anyimportantpassage,duct,or orifice in thebodymaybe foundcongenitallyobliterated forexample,thepharynx, oesophagus,duodenum, ileum, rectum,urethra,vagina, auditorymeatus,nasalduct,eventhe aorta itself(coarctationof theaorta).Nearlyall the writerswho have interested them-selves in thisquestionofcongenitalobliteration ofducts andpassageshave remarked thattheyoccuralmostexclusivelyin the situation of what I havotermedembryologicevents. This isparticularlytrue in relation to the duodenum. Thepointatwhich the common bile-duct enters the duodenumis thespotat which the diverticulum buds outfrom theembryonic gutto form the liver. Theduodenum isaptto beconstrictedimmediatelyabovethebile-papilla; occasionallyit isintercepted bynperforated diaphragm,and severalspecimenshavebeencarefullydescribed in which thesecondpartofthe duodenum has ended in a cul-da-sac but in allthedescriptionsI have read the bile-duct enteredthe distalextremityof theimperforate duodenum.These facts show that theprimitive gutin theOBLITERATION OF BILE-DUCTS 45immediateneighbourhoodof thebile-papillais theseat of muchactivity duringfratallife,and I amdecidedlyofopinionthat the factors which lead toobliteration of the main bile-duct in ante-natal lifeare thosewhichareresponsibleforimperforationsofthepharynx,duodenum,ileum, anus,etc.FIG. 8. Parts concerned in animperforate duodenum. P.pylorusandfirsthalf of the duodenum. D.secondhalfoftheduodenumAviththe commonduct andgall-bladder,G.B.Fromwhatweknowofcongenitalobliteration ofthe ileurn it is fairto assumethat there aredegreesofnarrowingor stenosis connectedwiththecommonbile-duct,and that a morbidprocess beginninginante-natal life need notnecessarilybecompleteatbirth,but continues inpost-natallife. This isborne outbya casereported by Ashby.Agirlagedsevenyearshad suffered fromjaundicefor46 DISEASES OF THE BILE-DUCTSthirtymonths. Thecommonbile-ductwasobliteratednearthe dirodenumandtheductsbehind theobstruc-tion,includingthecysticduct,weregreatlydilated,and contained sixteenpintsof bile-stained mucus.Thesameobservationappliesto thefollowingr:ise :Agirlbecamejaundicedat theageof threeyears,and it continued until she was nineteenyearsofage.ShewasoperateduponbyTroves,whofoundthegall-bladderdistended withmucus,faintlytingedwithbile;thecommonduct was not half an inch inlength, impervious,and ended as a fibrous nodule.Cholecystenterostomywassuccessfullycarried out.Tenmonths after theoperationthe skinwasslightlyjaundiced.A similarexplanation probably appliesto a casereported by Edgeworth.Hispatientwas agirlagedfourandahalfyears,with an abdominalcyst,whichheopenedand removed 29 oz. ofbile,undertheimpressionthat it was a dilatedgall-bladder.Thechilddied,and at thepost-mortemexaminationthegall-bladderandcysticductwerefoundatrophied,but thecyst representedanenormouslydilatedcommonbile-duct;its duodenal end was stenosed.ThespecimenrepresentedinFig.9 is referred tobyFrerichs asbeing preservedin the AnatomicalMuseum at Hreshm. The common andcysticductwere involved in thedilatation,whichcontainedbile.In relation to morbid conditions of the bile-ductsduringfoatallife,referencemaybe made to someOBLITERATIONOF BILE-DUCTS47observationsof Still onbiliarycalculi in children.He finds there is a muchgreatertendencyfor theformationofgall-stonesduring early infancythanFIG.9. Enormousdilatationofthe commonbile-ductsecondarytoobstruction of the duodenalorific. Fromafemaleinfant.(AfterFrerichs.)in laterchildhood,andherefersto Thomson's obser-vation thatnearly all,if notall,the calculi foundinthe newborn are formedduringintra-uterine life.Healso refers to an observationbyBouisson,whofoundgall-stonesin an infant associatedwith some48 DISEASES OF THE BILE-DUCTSnarrowingof the common bile-duct. Still hascollected five cases of intensejaundicein m-w-boniinfants, due,as wasproved byexaminationpoutmortem,to calculiimpactedin the ducts. It is fairto assumethatthesamemorbidprocessinante-natallife whichobliterates the ducts is alsoresponsiblefor theproductionof the calculi(see Chap. V).In contrast to obliteration of thebile-duct,someexamplesofverygreatdilatation of thegall-bladderhavebeen described in children withoutanyobviousevidence of obstructionorjaundice. Amongthebestknown of these is a case recorded withgreatcareanddetailbyVincent. Thegirlwaseightandahalfyearsofageand hergall-bladdercontained threelitres of fluid.Cholecystotomywasperformed,butthe child died. No definite obstruction was foundin the ducts.In one case the dilatedgall-bladdercontainedthree litres ofbile andmucus. This littlegirl, agedtwoandahalfyears,recoveredfromcholecystotomy,whichwasperformed byMiller Brown. Tln-iv wasnojaundiceand no obvious obstruction to thecommon duct.REFERENCES.Ashby, Henry,"Two Fatal Cases of Obstructive Jaundice inChildren." Ned.Chronicle, 1898,x, n.s.,p.28.Bland-Sutton,J.,"OnUK- Value of theSystematicExaminationofStill-bornChildren." Med.-Chir.Trans., 1884,lxvii,p.157.Brown, Miller,"CongenitalDilatation of the Gall-bladder andBile-duct." Amer.JournalofObstetrics, 1903, xlviii,p.182.REFERENCES 49Edgeworth,F.H.,"Case of Dilatation of theCommonBile-ductsimulatingDistension of the Gall-bladder.Lancet, 1895,i,p.1180.Emanuel,J.G.,"ACase ofCongenitalObliterationoftheBile-ducts in which there was fibrosis of the Pancreas and theSpleen."Brit.Med.Journ., 1907, ii,p.385.Frerichs,Prof. -DiseasesoftheLiver,SydenhamSociety'stransla-tion, 1861, 11,p.461.Hawkins,F.H., "CongenitalObliteration of the Ductus Com-munisCholedochus." Path. Soc.Trans., 1895,xlvi,p.76.Oxley,M.G.B., "CongenitalAtresiaoftheDuodenalOpeningoftheCommonBile-ductinanInfantproducingalargeAbdo-minalTumour."Lancet, 1883, ii, p.988.Rollcston,H.D.,"Congenital SyphiliticObstruction of theCommonBile-duct."-^- Brit. Med.Journ., 1907, ii,947.Rolleston,H. D. DiseasesoftheLiver, Gall-bladder,and Bile-ducts,1905.Still,G.F.,"BiliaryCalculiinChildren." Path.Soc.Trans.,1899,1,p.151.Thomson, J.,"OnCongenitalObliterationof theBile-ducts."EdinburghMed.Journal, 1892,xxxvii,pp.523, 604,and724.Treves,SirF.,"ACase of Jaundice of Sixteen Years'StandingtreatedbyOperation." Practitioner,1899,Ixii,p.18.Vincent,E.,"DelaCholecystotomiechezles Enfants." RevuedeChirurrjie, 1888, viii,p.753.CHAPTER VGALL-STONES: THEIRFORM,STRUCTURE,COMPOSITION,ANDMODE OF FORMA-TIONClassification.Naunyn arranges gall-stonesintosixclasses,accordingtotheircomposition:(1)Pure cliolwtcrni .v/owr.s-. These arehard,oval,orroughly spherical,seldom facetted.Theyarewhite,oryellowishandtranslucent,or morerarelybrownorgreenishonthe surface. On sectiontheyarecrystalline,but not stratified.They varyinsize from acherryto apigeon's egg.(2)Laminated cliolrxh'rhi xtoiirt*. Thesemaycon-tainnearly90percent, ofcholesterin,theremainingconstituentsbeingbilirubin-calcium in the brownandbiliverdin-calcium in theirgreen parts.Thesestones are hard butmaybe friable whendry. Theyare oftendistinctlyfacetted and on sectiondisplaylamina) which are colouredyellow,brown,andevengreenorred. In size and formtheyresemblepurecholesterin calculi. The externallayersareusuallyvitreous orearthy,but the structure iscrystallinetowards the centre of the stone.GALL-STONES 51(3)Thecommongall-bladderstones. The bulk ofgall-stonesare included in thiscategory:theyvaryinsize, form,andtint,and aredistinctlyfacetted. Their surfaces areusuallyyellow,butoftenbrown or white;theyare often nolargerthan thehead of apin,andrarelyexceed the dimensions ofalarge cherry.When freshtheyare often softandcan besqueezedinto apulp.On sectiontheyAFIG. 10. Agroupofcommonfacettedgall-stones.arelaminated,and within the nucleus there is fre-quentlyacavityfilled withyellowalkaline fluid.Such calculi do not exhibitanydistinctcrystallinestructure to thenakedeye.(4)Mixed bilirubin-calciumcalculi. Thesestonesareusuallyasbigas acherry.Asolitarystoneiscommon,butgroupsof three or fourmaybefoundin thegall-bladderorlargebile-ducts. Whenmultiple theyare facetted. These stones contain25percent, ofcholesterin,the remainderbeing52 DISEASES OF THE BILE-DUCTSbilirubin-calcium. Thenucleusischolesterin,coveredbythicklayersof darkbrown material whicheasilyflakes off.(5)Pure bilirubin-calcium calculi. These stonesvaryin size from agrainof sand to apea; theyoccurin twoforms :Fia. 11. Alargecholesterincalculusinsection.(a)Assolid,brownish-black concretions aboutthe size of apin'shead withrough, irregularsin- faces.Theyarewaxy,and show atendencyto weldtogether.(/>)Theseare,as arule, small,steel-greyorMack,with apronouncedmetallic lustre.Theyarehardandbrittle,and have aspongytexture,and inGALL-STONES 53the midst of the meshes there are smallgranuleswith a metallic lustre.Bilirubin-calcium is the chief constituent of thesecalculi,but there arealways present,and often inFIG. 12. Agroupofbilirubin-calciuuigall-stones.considerablequantities,biliverdin- calcium, bilifuscin,andcholesterin in minutequantity.(6)Rarer forms.(a) Amorphousandincompletelycrystallinecholesteringravel.Thesevaryin sizefromagrainof sandtothatofalargepea,andoftenFIG. 13. Gall-stonescomposedofchalk.(Calciumcarbonate.)look likepearls. Theyhave a nucleus of bilirubin-calcium enclosed in cholesterin.(b)Calcium carbonate calculi(calcareousstones.)These are rare. The museum of the MiddlesexHospitalcontains a set oftwenty spiculatedchalk54 DISEASES OF THE BILE-DUCTS(calcium carbonate)stones removed from thegall-bladder after death.(c)Concretions with included Ind'n-*. (Jail-stonesnotinfrequentlyhave a nucleus whichmayberecognisedas anindependentcalculus. Suchmaybe calledconglomerate gall-stones.Foreignbodies,such as aroundwormor aportionof afluke,aneedle,and aplum-stone,have beenfoundingall-stones.(.sed.(Fromacancerousgall-bladder.)andpneumococcus,are oftenpresentin thegall-bladder,andthus act ina two-foldcapacity,fortheysetupa catarrhalconditioninthemucousmembraneof thegall-bladderwhichleads to theproductionofGALL-STONES57cholesterin,andclumpsofbacilli form nuclei aroundwhich itmaycollect.Manyobservations have beenpublisheddrawingattention to thefrequencywith whichtyphoidfeveriscomplicatedwithCholecystitis typhosaand thetyphoidbacillus hasbeen found in thegall-bladderyearsafter thepatientshave recovered from thefever; moreover, clumpsof these bacilli andof theBacillus coli have been isolated from the nuclei ofgall-stones(see Chap. II).The relation betweenmicro-organismsandgall-stoneshas beenexperi-mentallyestablished.(Gilbert,Fournier, Girode,Mignot,Hanot,andothers.)Experimental experiencehas alsotaughtthatgall-stonesdo not follow virulent infection of thegall-bladder,but the most successful results areobtained after theinjectionof attenuated culturesinto thegall-bladder.Thefavouringconditions for the formation ofgall-stonesare catarrh of theepithelial liningof thegall-bladderand the bile-ducts and thepresenceofmicro-organisms, especiallythe Bacilluslyphosus.ThesuccessfulexperimentalproductionofabiliarycalculusrepresentedinFig.16 was obtainedbyMignotin thefollowingway:Asmallcompressimpregnatedwithapurecultureof Bacterium coliwasintroducedintothegall-bladderof adog,December,1897. Themicrobewasobtainedfrom a calculouscholecystitisinmanandattenuated.58 DISEASES OF THE BILE-DUCTSSix weeks later thedogwasagain operated uponandthecompressremoved fromthegall-bladder;atthe same time a thread 2 cm.longwas fixed intothegall-bladderwall and the free end allowed tofloat in itscavity.InJune, 1898,cholecystectomywasperformedon thelivingdogandtwocholesterincalculiwere foundon the threadin thegall-bladder.FIG. 16. Gall-bladder of adogopcni'd li.ngitudinally sli\viiv_ctwogall-stonesformed around a threadexperiment, illyintroduced(Mignot)..Mignotfound that aslongas the bacteria retaintheir virulencetheydo not formcalculi,butonlyasediment mixed withpus.The attenuation of the microbe is best obtainedbygrowingthe bacteria for some months in bile towhichconstantly decreasingamounts ,f broth art-added. \VhenSufficientlyattenuatedtheyare nolonger pathogenicwheninjectedinto the cellulartissue of animal.-.GALL-STONES 59Homansrecorded a case of interest in relation tothisexperimentand also ofimportancein relationto therecrudescence ofgall-stones.Heperformed cholecystotomyon a womanagedthirty-eight years,and removedninety-seven gall-stonesandclosedthegall-bladder (cholecystendysis).Oncountingthegauzedabs one wasmissing,andFIG. 17. Twogroupsofgall-stonesformedaroundathreadaccidentallyleftinagall-bladder (Homans).couldbe felt in thegall-bladder;this wasreopened,the dabrecovered,and thegall-bladderstitched totheabdominalwoundand drained.Twentymonthslater therewasrecurrence ofsymptomswhichled toasecondoperation,andonopeningthegall-bladderthe calculirepresentedinFig.17 were removed.Homansstates that the thread on whichtheyareformed was that used to close thegall-bladderatform60DISEASES OF THE BILE-DUCTSthetime the swab wassequestered,and it had notbeenremoved.Gall-stones form onpiecesofcatgutused assutures forsecuringthegall-bladderto the abdo-minalwallintheoperationofcholecystotomy(SinclairWhite,HamiltonDrummond).FIG. 18.Quadrilateralgall-stones.A. Insection. B. Entire.Iiiregardto the recrudescenceofgall-stonesaftercholecystotomythefollowing observation, publishedbyKehr, lias,,as Korteremarks,the value of anexperiment:Twelvecystotomised patients complainedt'pain,gastrictrouble,andcolic. Thegall-bladder regionGALL-STONES 61waspainful,the scarswollen,andtherewasevidenceofcholecystitis.In five hepuncturedwith a fineneedle and withdrew turbidbile,which containedBacterium coli. This furnishesstrongevidence forthosewhoadvocatecholecystectomy.Itmightbeurgedthat concretions are foundoccasionallyinthebile-ductsof thenewlybornwhosebile is sterile;but these are soft bilirubin-calciumconcretions,and it is not out ofquestionthattheymaybe theproductionsofinflammation, especiallywhen we remember thatcongenitalobliteration ofthe mainbile-ducts,and even of thegall-bladder,is attributed to ante-natal inflammation(see Chap.IV).Small bilirubin-calcium concretions not infre-quentlyplaythepartofforeignbodies and establishacholelithiasis.Naunynwrites that hehas severalsetscontaining twentyorthirtystones out of onegall-bladder;in the centre of eachstone there is abilirubin-calcium concretion(p. 105).Facetting.Asolitary gall-stone,free to swim inthe bile or contained in thegall-bladder,isusuallyovoidandsmooth onthe surface. Whena stone istightlyembracedbythe wallsof thegall-bladderitssurface isnodular,the nodulesbeingcasts of thepitsin the mucous membranelyingin contact withthegall-stone;thus alarge gall-stoneis often a castof the interior of thegall-bladder.Avery largestone in agreatlydistendedgall-bladder mayhave62 DISEASES OF THE BILE-DUCTSasmoothsurface,as in thegall-stone Fig.19,whichis thelargest specimenI haveremoved: it measures13 cm. roundthe baseand 19 cm. round themajoraxis. Thepatient,a womanaged50years,hadagall-bladdersolargethat thisbigcalculus couldfloat about in the bile it contained.11). Asolitary-_;;illstum-sucvcssfullyn-niovod from aninflamed^all-hlaiMrr.Nat.size.(Mu^umoftheMicUll.">.Gilbert etGerode,"CholecystitePurulenteProvoquee par!Bacille d'Eberth."ComptesRendus Soc. deBiologie, 1893,ninthseries, v,p.'.)">''>.Hanot andLetienne,"Note sur Diverses Variett's de Litliian-Biliare."ComptesRendusSoc. deBiologie,1895,tenth seiLea,ii,p.s.">7.Homans, J.,"Gall-stones formed around Silk Suturest\\cntymonths afterrecoveryfromCholecystotomy."Ann"897,xxvi,p.114.Kehr,Hans,"Wie N'erhiilt es sich mitdenK'vidivrii u;u-li un.-.-rnGhdlenflteinoperationenP"Langenbech'sArchh-, Um,lid.l.xi,s. 173.Mignot, R., "L'OrigineMicrobienne des Calculs Biliaires."-ArtA//'< rs'/'.//,,TJsecondary1 theimpact ion t' a^all-stonein the.-\>ticduct. Thetriangularpatchofliveris sometimescalledKii-d-l's lobe.su>rin]stonesinthegall-bladderis dueto thepresenceof acementingsubstanceadmirablysuited to thepurpose namelybilirubin-calcium.Moreover,thegall-bladderis aplaceofrefugeinwhich thenewlyCONSEQUENCESOF GALL-STONES 69formed concretions canundergofartherdevelopmentundisturbed,andtheir consolidation favouredbythecompressionexertedbyits muscular coat.The number and size ofgall-stonesin thegall-bladdervary greatly.Thelargest gall-stoneIhave removed isrepresented by Fig.19;thegreatestnumber ofbiliaryconcretions which havecome undermyown notice in onepatientis 1321.It is not uncommon to find 100 calculipresent.Naunyncounted 5000 in agall-bladderand Otto7000.The conditions of calculi in thegall-bladderareworth comment. Whenthecysticduct is occludedbya calculus no bile enters thegall-bladder,but itbecomes filled with mucus andslowly enlarges,andmaybecomebig enoughto be obvious on clinicalexamination. Intypical examplesof this condition(hydropsvesicxfellese)thegall-bladderis a thintranslucent, pyriformbag,and the calculi it containsconsistusuallyof almostpurecholesterin and floatfreelyabout in the tliin mucus. Agall-bladderenlargingin thiswayusuallyhas attached to it atriangularand colourlessprocessof theadjacenthepatictissue.In otherspecimensthe mucus of thegall-bladdermaybe soinspissatedthat thegall-stonesareimbedded in it as if it were a mere stiffpaste.(Fig. 25). MayoRobson found the mucus in acalculousgall-bladder equalin consistence tojelly,TO DISKAsr.sor Till-: BILE-DUCTSami ho removed it entire;the mucus Wiiii* trans-parent,tliis east of the o-all-bhuUerwith the stones!'"l-'i... J I. A:;-all-l>la(llci-with^:ill-stoin'siinbiMl.lc.l in ti nil innniliniliin-ralciiiiii i-alruliimbeddedinther..nt'iits callMa.M.T."uall-st->ncsinMpiOK.-Y.ilinpositionivM'inlli's \vliat a rook would call*'stoiu-s inas]>ir"(Kij^. 12")).In surh i-ouditi'-ns tlu walls of thepian-smiu'tinu's a centimetre or more in thickness andCONSEQUENCESOK (JALL-SToNKS 71oftenverytonsil,indic;i!in;-;I I . i Jdiec of :i, moresevere form of ch Case of Fistula." Mcd.Timet////ftuette,I^TI;.11,j,.i'o^.Bland-Sutton, J.,"n S..m' Cas.-s ofEmpyemaofgall-bladder,31INDEX253Gall-bladderactinomycosisof,36anatomyof,6absenceof,11anomaliesof,11axialrotationof,75calcificationof,36cancerof,131diverticulaof,74empyemaof,31fistiilse,80gangreneof,34hour-glass,12,72hydropsof,69infectionsof(see Cholecystitis)inhernia,175injiiriesof,242operationson,213perforation,28,83papillomaof,136sclerosisof, 36,177sloughingof,34typhoidinfectionof,17ulcerationof,34Gmelin'stest,14Gall-stoneileus-causesof,108clinicalcharactersof,115treatment,118Gall-stones-ball-valveactionof,92cancerand,133changesin,64classificationof,50compositionof,50diagnosisof,182diagnosticlocalisation,178encapsulationof,73experimentalproduction,57facettingof,61Gall-stones(continued)formationof,64fractureof,76inampulla,97,153inappendix,87incolon,109incommonduct,90incysticduct,77indiverticula,74infaeces,172ingall-bladder,67inhepaticduct,101ininfants,48inintestine,107inintrahepaticducts,102inMeckeliandiverticulum,86inperitonealcavity,81instomach,82inurinarytract,87invermiformappendix,87micro-organismsin,56nucleusof,34originof,55recrudescence,60,239resultsof,67skiagraphyof,180symptoms,165treatmentof,192Generalcysticdisease ofliver,121Hepaticabscess,235Hepaticarteryaneurysmof,37erosion,38Hepaticductanatomyof,4cancerof,141dilatationof,101254INDEXHepaticduct(continued)operations on,229stonesin,101strictureof,26suppurationin,102ulcerationof,102Ilydropsvesicaefellece, 31,09Intermittinghydrops,71Intestinalobstruction(seeGall-stoneileus}107Intra-hepaticductsanatomyof,2cancerof,141castsof,105dilatationof,122stonesin,102Islands(ofLangerhans),155Jaundice(icterus)andwanderingspleen,162black,159catarrhal,24causesof,186fcocesin,171haemorrhage,173obstructive, 186,187ofpancreaticcancer,158ofhepaticcancer,159pruritus, 170,195toxsemic, 157umobstructivo,187urinein,171withcholethiasis,168yi-llowvisionin,186Liver-abscessof,235131Liver(continued)cancerof,131cystsof,121hydatidsof,126linguiform lobe,175Riedel'slobe, 173,176Micro-organismsinbile, 2:?inbiliaryabscess,100incholangitis,23B.typhosus,17tuberclebacillus,28incholecystitis,32,54B. coli conuna,/i