PRACTICAL CONSIDERATIONS : THE BILE DUCT. 1731 



and gall-stones in old cases of empyema of the gall-bladder. Its anatomical relations 

 to surrounding structures and spaces should therefore be carefully studied. 



Cholelithiasis. — As the normal expulsive efforts of the muscular walls of the 

 gall-bladder are usually aided by the contraction of the abdominal muscles during 

 exercise, gall-stones are more commonly found in persons of sedentary habits, in 

 invalids, and in females, especially in multipara. Tight lacing, by depressing both 

 liver and gall-bladder, as well as kidney {^vidc si(pra), is also a distinct predisposing 

 cause. Bacterial infection with the colon or typhoid bacillus, and more rarely with 

 other organisms, is, however, a frequent exciting cause of the hypersecretion and 

 epithelial proliferation which lead to the formation of gall-stones. 



The presence of stones in the gall-bladder may be unaccompanied by symptoms, 

 or may cause the development of such phenomena as either have no distinct ana- 

 tomical bearing (biliary fever and secondary visceral lesions) or as have already 

 been considered (abscess of the liver, empyema of the gall-bladder, fistulae, etc.). 

 There are mechanical accidents, however, connected with the emigration of the 

 stones which will be considered from the anatomical stand-point in relation to the 

 biliary ducts. 



The Cystic and Common Bile-Ducts. — The cystic duct is the narrowest 

 portion of the biliary passages. Its calibre would permit the passage of a probe 

 through it into the hepatic duct, but the irregular folds of its mucous membrane 

 (sometimes regarded as constituting a "spiral valve," — the valve of Heister) usu- 

 ally effectually prevent satisfactory probing. Its muscular fibres are better devel- 

 oped than are those of the other biliary ducts. The passage of a stone through it 

 is attended by ( i ) colicky pains of the sort usually associated with violent mus- 

 cular contraction ; (2) continuous pain resembling that due to an acute cholecystitis 

 (the two conditions being often mistaken one for the other), and due (a) to the slow 

 progress of the stone in the cystic duct, in which it takes a rotary course owing to 

 the arrangement of the mucous folds ; (^b) to the acute inflammation which usually 

 accompanies an attack ; and (<:) to the stretching and distention of the gall-bladder by 

 retained secretions (Osier). The pain may be even more intense, and is apt to be 

 accompanied by (3) vomiting, {\) profuse sweating, and (5) great depression of the 

 circulation, all due to reflex irritation of the sympathetic plexuses and the pneumo- 

 gastric. There may be (6) a rigor, either purely nervous or due to retained secre- 

 tions and a concurrent lithaemic inflammation. In the latter case there will be (7) 

 fever from the accompanying toxaemia. 



If the stone passes into the intestine, all the symptoms usually disappear. It 

 may cause (8) intestinal obstruction, and is a far more common factor in the pro- 

 duction of this condition than are enteroliths. Of 149 cases of this type of obstruc- 

 tion, 133 were due to gall-stones and only 16 to enteroliths, and 10 of these had 

 gall-stone nuclei. Although a stone of considerable size may pass through the duct, 

 those large enough to bring about intestinal obstruction usually enter the duodenum 

 by ulceration. If the stone becomes impacted in the cystic duct, (9) dilatation of 

 the gall-bladder with mucus (hydrops) occurs ; or (10) cholecystitis, acute or chronic, 

 may follow {vide supra). Calcification and atrophy of the gall-bladder are not 

 uncommon sequelae. 



The stone may pass into and obstruct the common duct. This is about three 

 times the diameter of the cystic duct, and, therefore, many stones which have gi\-en 

 rise to the above symptoms pass through it easily. If a stone permanently occludes 

 it, there will usually be deep and persistent jaundice, clay-colored stools, vague and 

 dull hepatic and shoulder pain, rarely colicky in character, and absence of septic 

 phenomena and of enlarged gall-bladder, the latter symptom occurring in not more 

 than 10 or 12 per cent, of cases of calculous common-duct obstruction. A stone may 

 pass as far as the ampulla of Vater and act as a "ball-valve," in which case there 

 will be variable jaundice and ague-like . paroxysms of chills, fever, and sweating, 

 accompanied by hepatic pains and gastric disturbance (Osier). The mechanical 

 effect of a stone in such a position, plus the resulting nerve irritation and infective 

 cholangitis, sufficiently explains these phenomena. 



Occlusioji of the common ducts may occur from other causes, as stricture follow- 

 ing ulceration due to stone, the presence of lumbricoid worms, echinococci, etc., or 



