GALL-STONES AND THEIR CONSEQUENCES CHOLELITHIASIS. 



edges, corners, and smooth surfaces, or they have convex and concave 

 facettes, which give them a peculiar appearance. Biliary calculi have 

 a low specific gravity; when recently removed, they may be mashed 

 by the fingers ; when dried, they usually split, and finally break down 

 into dust. Biliary calculi vary greatly in color ; some are whitish, or 

 pale yellow, from slight imbibition of bile, others are dark brown y 

 and others still are greenish or blackish. They often consist of va- 

 rious layers, and light-colored strata may alternate with dark ones. 

 Calculi, consisting chiefly of cholesterin, have a marked, striated crys- 

 talline structure, while those that contain chiefly biliary coloring mat- 

 ter with lime have an earthy fracture. Most biliary calculi are chemi- 

 cally composed of cholesterin, and have a small amount of bili verdine 

 only about then* nucleus ; others consist of a mixture of cholesterin 

 and biliverdine ; the latter is sometimes distributed regularly through 

 the mass, sometimes there are alternate layers of cholesterin and of 

 the coloring matter of the bile with lime. We rarely meet calculi con- 

 taining no cholesterin, but composed of bile-pigment and lime, or of 

 carbonate and phosphate of lime (Lehmann). 



In most cases no structural changes can be discovered in the coats 

 of the gall-bladder, even when it contains numerous calculi with sharp 

 edges. But occasionally, particularly in the fundus of the bladder, 

 we find a considerable injection and puffing of the mucous membrane, 

 or there is an ulcerative loss of substance of variable size and depth. 

 The ulceration may lead to perforation of the gall-bladder. If this 

 occurs before the wall has become adherent to neighboring parts, the 

 contents enter the peritonaeum and cause general peritonitis. If, on 

 the other hand, the gall-bladder be perforated after it has formed firm 

 adhesions with neighboring parts, there may be communication with 

 the intestines or perforation outwardly. In some cases the inflamma- 

 tion induced by gall-stones is less destructive. The walls of the blad- 

 der are thickened, and, after a while, undergo cicatricial retraction ; 

 the contents become dry and chalky. And, finally, in such cases we 

 find the biliary calculi embedded in a chalky mass, and firmly enclosed 

 by the shrunken and atrophied gall-bladder. 



In the gall-ducts of the liver, biliary calculi may excite suppurative 

 hepatitis. In the excretory ducts, large calculi either cause ulceration 

 and perforation or complete closure of the duct, so that the states de- 

 scribed in Chapter HL, excessive biliary congestion, or, if the cystic- 

 duct be closed, hydrops vesicae felleae result. In some cases the bile- 

 ducts are so dilated, by the pressure of the bile from behind, that the 

 latter squeezes past the calculi, or that even comparatively large cal- 

 culi are forced into the duodenum. 



SYMPTOMS AJSTD COURSE. On autopsy, large calculi or numerous 



