DILATATION OF THE BILE-DUCTS. 731 



gall-bladder becomes more and more distended by the secretion. This 

 state is called hy drops vesicco fettece. 



ANATOMICAL APPEARANCES. According as one or other of the 

 above causes prevails, the anatomical appearances vary so greatly, 

 except in the general effect of the constriction or closure of the excre- 

 tory bile-ducts, that we snail refrain from giving a detailed description 

 of them. If its mouth be entirely closed, the ductus choledochus may 

 attain the size of the small intestine, and the dilatation extends through 

 the ductus hepaticus and its branches to the capillary gall-ducts. The 

 gall-bladder is also dilated, but its dilatation is not in proportion to 

 that of the gall-ducts, because, from the acute angle at which it opens, 

 it is compressed by the dilating ductus choledochus. The liver shows 

 the changes that we have described as characteristic of the highest 

 grade of biliary obstruction ; it is at first enlarged, and on section the 

 dilated gall-ducts look like large cysts filled with bile ; subsequently, 

 they may become smaller, from atrophy of the liver. In hydrops 

 vesicce feller the gall-bladder becomes a translucent, tense cyst, as 

 large as a fist, or a child's head even, which contains a serous fluid, re- 

 sembling synovia. Its muscular filaments are separated and atrophied, 

 the mucous membrane has lost its structure, and has acquired the look 

 of a serous membrane. In some cases closure of the cystic duct leads 

 to atrophy of the gall-bladder ; its mucous and bilious contents become 

 inspissated, and changed to a chalky mass, while the walls are thick- 

 ened and atrophied by chronic inflammation. Finally, there remains 

 only a hard tumor, as large as a pigeon's egg, filled with a chalky pulp. 



SYMPTOMS AND COURSE. Contraction and closure of the ductus 

 hepaticus and choledochus are characterized by the symptoms of exces- 

 sive biliary obstruction, uncomplicated by those of gastro-duodenal 

 catarrh, but occasionally accompanied by those of neoplasia or other 

 growths in the abdomen, or of chronic peritonitis, or of gall-stones, 

 etc. The icterus is more decided, and the fasces more discolored than 

 in any other form of biliary obstruction. We usually find the liver 

 enlarged, and if the ductus choledochus be closed we also feel the full 

 and distended gall-bladder. Later the consecutive dilatation of the 

 liver may also be observed. If we find cancerous tumors in the abdo- 

 men, if there has been colic from gall-stones, or if any other symptoms 

 indicate the variety of the closure, the diagnosis becomes more certain* 

 In most cases it is only possible to recognize the closure, without beinp 

 able to make out its cause. 



Hy drops vesicce fellece is readily diagnosed, if it be simple and noi 

 complicated with obstruction and closure of the ductus hepaticus or 

 choledochus. If we find a pear-shaped, movable, occasionally fluctuat- 

 ing tumor starting from the incisura vesicae felleae, in a patient who ia 



