BILIARY CALCULI 455 



were dominated by the observations and conclusions of .Naunyn*^ 

 and his pupils. Former observers, having learned that bile normally 

 contains cholesterol (Hammarstcn found from 0.06-0. IG per cent, in 

 human bile), sought the cause of gall-stones in either an increased 

 elimination of cholesterol by the liver, or a decrease in the power of 

 the bile to hold the cholesterol in solution. Thus Frerichs, finding 

 that the presence of large amounts of bile salts and an alkaline re- 

 action favored the solution of cholesterol, imagined that a diminu- 

 tion of either bile salts or alkalinity led to the precipitation of the 

 cholesterol. Naunyn and his pupils, however, not finding that the 

 amount of cholesterol present in the bile depends upon the amount 

 taken in the food or the amount present in the blood, and that it 

 did not vary in disease, except when gall-stones were present, con- 

 cluded that the cholesterol of the bile is neither a product of general 

 metabolism nor a specific secretion-product of the liver. Finding 

 that pus and the secretions from inflamed mucous membranes (bron- 

 chitis) contained as much cholesterol as did normal bile, and often 

 more, they concluded that the chief source of cholesterol in gall-stone 

 formation was from the degenerating and desquamated epithelial 

 cells of the gall-bladder and bile tracts. This idea was supported by 

 the large amount of cholesterol found in the contents of gall-bladders 

 shut off from the common duct, and by the formaton of gall-stones 

 in such isolated gall-bladders. Some further evidence has since been 

 brought forward in favor of this same view,^^ but others, finding 

 no abundance of cholesterol in the wall of the gall-bladder have not 

 accepted this origin.'*'* 



On the basis of Naunyn's hypothesis the ordinary steps in the for- 

 mation of a cholesterol concretion are as follows: Some injury to the 

 mucous membrane of the bile tracts is the starting-point; this injury 

 is usually produced by infection, the colon and typhoid bacilli being 

 the most common organisms in this process. ^^ Through the degenera- 

 tion of the epithelial cells an excess of cholesterol is formed, while at 



*2 An English translation of this classic work, by A. E. Garrod, has been pub- 

 lished by the Sydenham Society, 1896, vol. 158. 



*^ Thus Wakeman (quoted by Herter, Trans. Congress Amer. Physicians, 1903 

 (6), 158) was able to cause an increase in the cholesterol of the bile in the gall- 

 bladder of dogs by injecting into it HgClo, phenol, or ricin. At first the choles- 

 terol seems to be contained largely in the degenerating desquamated cells. Also 

 the interesting case of a cholesterol calculus in a pyosalpinx, described by Thies 

 (Arb. Path. Inst. Tubingen, 1908 (6), 422), shows the possibility of an inflamma- 

 tory origin for such concretions, and independent of bile. 



■«^ Aschoff, Miinch. med. Woch., 1906 (53), 1847 and 1913 (60), 1753; Aschoff 

 and Bacmeister, "Cholelithiasis," Gustav Fischer, Jena, 1909; Laroche and 

 Flandin, Compt. Rend. Soc. Biol., 1912 (72), 660. 



8^ See Cushing (Johns Hopkins Hosp. Bull., 1899 (10), 166), who produced 

 gall-stones experimentally by injecting typhoid bacilli into the circulation after 

 injuring the gall-bladder. Literature on the relation of bacteria to gall-stones 

 given by Funke, Proc. Path. Soc, Philadelphia, 1908 (11), 17; also see Rosenow 

 who finds that streptococci are often responsible (Jour. Infect. Dis., 1916 (19). 

 527). Grieg notes the frequent occurrence of gall-stones in rabbits immunized 

 with cholera vibrios (India Jour. Med. Res., 1916 (3), 397). , 



