BILE CONCRETIONS. 419 



connection between the formation of bilirubin and bile-acids in the 

 liver? The investigations of STADELMANN teach us that this is not the 

 case. With increased formation of bile-pigments the amount of bile- 

 acids is decreased, and the introduction of haemoglobin into the liver 

 strongly increases the formation of bilirubin, but simultaneously strongly 

 decreases the production of bile-acids. According to STADELMANN the 

 formation of bile-pigments and bile-acids is due to a special activity of 

 the cells. 



An absorption of bile from the liver and the passage of the bile con- 

 stituents into the blood and urine occurs in retarded discharge of the 

 bile, and usually in different forms of hepatogenic icterus. But bile- 

 pigments may also pass into the urine under other circumstances, espe- 

 cially when a solution or destruction of the red blood-corpuscles takes place 

 in animals through injection of water or a solution of biliary salts, through 

 poisoning by ether, chloroform, arseniuretted hydrogen, phosphorus, 

 or toluylenediamine, and in other cases. This also occurs in man in 

 severe infectious diseases. It has also been claimed many times that 

 a transformation of blood-pigments into bile-pigments occurs elsewhere 

 than in the liver, namely, in the blood. Such a belief has been made 

 very improbable by the important researches of MINKOWSKI and NAUNYN, 

 AFANASSIEW, SILBERMANN, and especially of STADELMANN/ and in some 

 of the above-mentioned cases, as after poisoning with phosphorus, toluy- 

 lenediamine, and arseniuretted hydrogen, it has been disproven by direct 

 experiment. 



The icterus is also in these cases hepatogenic; it depends upon an 

 absorption of bile-pigments from the liver, and this absorption seems to 

 originate in various cases in somewhat different ways. Thus the bile 

 may be viscous and cause a congestion of bile by counteracting the low 

 secretion pressure. In other cases the fine biliary passages may be 

 compressed by an abnormal swelling of the liver-cells, or a catarrh of the 

 bile-passages may occur, causing a congestion of the bile (STADELMANN). 



Bile Concretions. 



The concrements which occur in the gall-bladder vary considerably 

 in size, form, and number, and are of three kinds, depending upon the 

 kind and nature of the bodies forming their chief mass. One group of 

 gallstones contains lime-pigment as chief constituent, another cholesterin, 

 and the third calcium carbonate and phosphate. The concrements 

 of the last-mentioned group occur very seldom in man. The so-called 

 cholesterin-stones are those which occur most frequently in man, while 



1 The literature belonging to this subject is found in Stadelmann, Der Icterus, etc., 

 Stuttgart, 1891. 



