Part 3 — CHAPTER II. PATHOLOGICAL CONDITIONS. (continued 2)

The Ascaris lumbricoides may be found in some of the bile passages, it having entered by the opening of the common duct into the intestine.

2. Affections of the Gall-bladder and Ducts.

The gall-bladder is sometimes wanting, this being the normal condition in the horse and some other animals. When thus absent, the hepatic ducts are so increased in size, as to be able to contain the accumulating bile in the intervals of digestion.

Inflammation of the gall-bladder and common duct, involving their mucous lining, is not uncommon. Such inflammation may be either catarrhal or suppurative.

Catarrhal inflammation may result in thickening or calcification of the lining membrane of the ducts and bladder, with the accumulation of such quantities of thick tenacious mucus, as to become a source of impediment to the flow of the bile, and thus give rise to jaundice. Such inflammation becoming chronic in the common duct, may result in great dilatation of the gall-bladder, from the accumulation of bile.

In many cases, this form of inflammation would seem to have originated in the duodenum, reaching the biliary passages by extension through the opening of the duct into the intestine. It may also result from the presence of calculi or parasites in the passages, or from inflammation of the liver.

Suppurative inflammation may attend different forms of fevers, or result from the presence of calculi. The gall-bladder, with the bile ducts, in such cases, may be filled 188with a purulent fluid, or the same may be found infiltrated through their walls.

Perforation of the walls of the gall-bladder may result from this form of inflammation, with escape of contents into the peritoneal cavity, inducing thus fatal peritonitis. Fistulous communication may also form between the bladder and colon, duodenum or stomach, or through the abdominal walls, adhesions having first taken place between these parts.

Dilatation, both of the bladder and ducts, may occur as a result of obstruction of the gall-ducts. That of the former may be very great, giving rise to a tumor that may be plainly felt through the abdominal walls. Dilatation of the ducts may involve either the common, or large hepatic ducts, or the smaller branches within the liver. Such dilatations may be sacculated in form, or general, involving the whole tube.

Morbid Growths.

Cancer of the walls of the gall-bladder is not unfrequent, and may be either primary or secondary. The cavity of the bladder may in this way become obliterated, and the common duct obstructed, thus inducing jaundice.

In a case examined for the Drs. Pettingill, the gall-bladder was as large as the fist, from scirrhus cancer; its cavity obliterated; adhered to the pylorus to which the disease had extended; and the bile ducts greatly dilated and filled with a large quantity of puriform fluid. The patient had been for many months extremely jaundiced.

Fibroid tumors are very rarely observed in connection with the gall-bladder.

Tubercular deposits may be found beneath its peritoneal covering.

Biliary Calculi. The presence of biliary calculi, or gall-stones 189in the gall-bladder, or some of the ducts, is a very common occurrence. These bodies are composed of the elements of the bile, largely however of cholesterine, sometimes in an almost pure state, in others, more or less mixed with inspissated bile. In many cases, a nucleus of nearly pure cholesterine will be surrounded by a deposit of biliary matter mixed also with scales of cholesterine.

Cholesterine is a peculiar spermaceti, or fatty-like substance, found not only in the bile, but also in the nervous tissues, insoluble in water, but soluble in æther or boiling alcohol. When found in a pure state, it is of a yellowish-white color, with the particles arranged in the form of shining thrombic scales.

Gall-stones may occur of all sizes, from a pin’s head to that of a hen’s egg. When small, they are generally numerous; in some instances fifty to one hundred being found in the gall-bladder at one time. When several are present in the bladder, they will be more or less angular or polyhedral in form from contact and attrition with one another. Where there are but one or two, the size may be considerable, while the form will be rounded, oblong or pear-shaped, and more or less regular.

These bodies, when first removed, are usually heavier than water, but, after being dried, become considerably lighter. They are inflammable, and may be reduced to almost pure charcoal by burning. After having being exposed to the air for some time, they are very liable to crumble more or less completely.

Position. 1. Gall-stones may be confined to the gall-bladder. This is the position in which they are more frequently found. There is every reason to believe that they may remain there for a long time without giving rise to any uncomfortable symptoms. We frequently find them after death in the gall-bladder of persons who, during life, exhibited no symptoms of their presence. They are liable, 190however, when present, and particularly if numerous or large, to give rise to a sense of weight and dragging in the part, and to occasional attacks of pain, derangement of the stomach and vomiting; and may also excite inflammation and ulceration of the walls of the bladder.

The presence of gall-stones, when in large numbers, may frequently be detected through the abdominal walls, as a hard resisting tumor, which, by grasping, may be made to elicit a rattling sensation, like pebbles in a bag.

2. Gall-stones may become impacted in the neck, or cystic duct of the gall-bladder. In this case, it is likely to give rise to an attack of biliary colic, with vomiting, etc. As long as it remains in this position there will be no jaundice. Their presence, however, may excite inflammation; yet we sometimes, in post-mortem examinations, find the neck of the gall-bladder blocked up by a calculus, when no symptoms of such an obstruction existed during life.

3. Gall-stones may form in some of the branches of the hepatic ducts within the liver. This is not a common point for the formation of these bodies. They are sometimes found, however, in cases of obstruction of the ductus communis. The concretions may be small and rounded, or branching casts of the tubes, resembling pieces of coral.

4. Gall-stones may be lodged in the ductus communis choledochus. This is one of the most common situations for these bodies, and they may reach the point, either from the gall-bladder, or from the ducts from the liver. While in this position, the calculus is likely to give rise to jaundice with paroxysms of severe pain, which will be repeated from time to time, until it passes into the intestines.

Effects. As already intimated, gall-stones may remain for an indefinite period in the gall-bladder or ducts, without giving rise to any symptoms. In many instances, also, they may undoubtedly pass the ductus communis when small, and be discharged by the bowels, without the knowledge of 191the patient. More frequently, however, the passage of these bodies is accompanied with paroxysms of severe pain, the location and character of which will usually serve to indicate the true cause. Where, however, the body is too large to pass, its presence in the gall-bladder or any of the gall-ducts, may excite inflammation and ulceration in those parts, and thus lead to perforation and discharge of contents into the peritoneal cavity.

Case.—Rupture of the Gall-bladder, with discharge of contents into the peritoneal cavity, followed by peritonitis and death.

Mr. De K. T——, of this city, aged about 60, had suffered from several attacks of severe pain in the region of the gall-bladder, which I had diagnosed as biliary colic, induced by the presence of a calculus. One morning in June, 1863, while working in his garden, he felt a sensation of something giving away in his side, which was immediately followed by an attack of severe pain. A chill and fever soon succeeded; and, in twenty-four hours, a violent peritonitis set in, resulting in death in four days.

Autopsy, thirty-six hours after death. Upon opening the cavity of the abdomen, the peritoneal membrane was found intensely inflamed at all points, and containing nearly a quart of greenish sero-purulent fluid. Slight plastic adhesions were found at various points, uniting the intestines to the abdominal walls, while old, firm and extensive adhesions were found between the same and the liver and gall-bladder. There were evidences that the latter had been largely distended, yet, through a distinct opening, the contents had escaped into the peritoneal cavity, leaving behind a single calculus of a regular oval form, and one inch of its long diameter.^[28]

From the appearance of the part, it would seem that the calculus had excited inflammation and ulceration in the walls of the gall-bladder, destroying the latter so completely, that the fluid contents were kept from escaping into the abdominal cavity, only by the adhesions that had formed, and that these had been probably torn away by the exercise of digging with the spade.

In many cases, the adhesions which are induced by the 192inflammation, will secure a more fortunate result, favoring the working of the calculus, by the ulcerative process, either into the duodenum or colon, and thus, in most cases, securing its passage per anum. In such instances, should an opportunity be had of examining the parts after death, traces will be found remaining, sufficient to indicate the point at which the escape into the bowel was effected.

In some rare instances, gall-stones have been vomited from the stomach. While it might be possible for such bodies to be carried from the duodenum into the stomach by a reversed peristaltic action, it is more probable that, in such cases, the calculus has found its way into the stomach by a direct fistulous communication with the gall-bladder.

Fistulous communications of a permanent character are sometimes left, after an ulcerative discharge of a gall-stone into some portion of the intestinal canal.

Gall-stones, after entering the intestinal canal, may become impacted, thus producing intestinal obstruction. Many fatal cases of this character have been reported. An interesting case of intestinal obstruction from this cause, was reported by Dr. Frieze, of Harrisburg, at the meeting of the American Institute of Homœopathy, in Philadelphia, in June, 1871. A lady sixty-five years of age, had been suffering severe pain in the bowels for over a week, with symptoms of obstruction, when, after a persevering use of injections, she passed a calculus of a cylindrical form, one and three-quarter inches in length, and four and one-half inches in circumference, and weighing four hundred and thirty-seven and one-half grains.^[29]

Gall-stones have, in a number of cases, been discharged upon the surface of the body, while in some rarer instances, by the ulcerative process they have worked into the ureter, and even into the vena cava and portal vein.

193