732 DISEASES OF THE GALL-DUCTS. 



not jaundiced, we may diagnose closure of the cystic duct and disten- 

 tion of the gall-bladder by mucous secretion, or hydrops vesicae felleae. 

 As it is almost always impossible to remove the cause of the con- 

 traction or closure of the bile-ducts, it is impossible to treat them suc- 

 cessfully. 



CHAPTER IV. 



GALL-STONES AND THEIR CONSEQUENCES CHOLELITHIASIS. 



ETIOLOGY. In spite of numerous works on this subject, the origin 

 of gall-stones is very obscure. Particles of mucus, or (far more rarely) 

 foreign bodies in the gall-passages, appear to play an important part 

 in the formation of gall-stones, for they form the nucleus in almost all 

 cases, and they at least form the point on which the solid constituents 

 of the bile may be deposited. It cannot be decided whether such 

 deposits occur when the bile is normal, or only when it is -somewhat 

 concentrated, or when of abnormal composition. As a combination 

 of chalk with bile-pigment is almost always deposited immediately 

 around the above-mentioned nucleus, and as this combination almost 

 always occurs in greater or less quantities, it is thought that excess 

 of chalk in the bile, from drinking lime-water, has something to do 

 with the formation of gall-stones. But, besides this, it is probable that 

 the bile from which gall-stones, rich in cholesterin, are formed, has only 

 a slight solvent power over cholesterin ; and as it has been found that 

 both cholesterin and biliary coloring matter with lime are dissolved by 

 tauro-cholic acid and tauro-cholate of soda, it was very natural to con- 

 sider a lack of tauro-cholic acid hi the bile, or a decomposition of the 

 tauro-cholic acid in the gall-bladder, as the possible cause of gall-stones. 



Gall-stones occur more frequently in women than in men, far more 

 frequently in old than in young persons ; and, without our being able 

 to explain why, they are particularly frequent in patients with carci- 

 noma of the stomach or liver. Perhaps this is somewhat due to the 

 catarrh of the bile-passages, which, as we said in Chapter L, often ac- 

 companies carcinoma of the li ver. 



ANATOMICAL APPEARANCES. The size of gall-stones varies from 

 that of a hemp-seed to that of a hen's egg. The smallest concrement? 

 are distinguished from gall-stones proper by the name of " biliary sedi 

 ment." Most frequently there is only one calculus, in other cases 

 there are a great number of them. Solitary stones are usually round 

 or egg-shaped, or they have exactly the shape of the gall-bladder. 

 Their surface is sometimes smooth, sometimes more rough and glandu- 

 lar. If there are several stones, they have almost always become 

 smoothed on the sides that touch and have a polyhedral form, with 



