IMPACTION OF THE GALL BLADDER,

WITH DISCHARGE OF 130 CALCULI.

Before giving the report of my case, it may be well to preface with a few remarks on the physical and chemical properties of gall stones, and their mode of formation.

Biliary calculi are concretions of different chemical materials, derived entirely from the constituents of the bile. These concretions may be found in any part of the liver, but the gall bladder is generally their nidus.

They vary considerable in size, shape, color, and specific gravity. In size they may be as small as a millet seed, or as large as a walnut, Merkel reporting one measuring five inches (0.127 metres) in length by four (0.102 metres) in circumference, and Blackburn mentions one which was four inches (0.102 metres) in length by four and a half inches (0.114 metres) in circumference, and weighing nearly three ounces (93.210 grammes). The size of the stones varies in proportion to the number, while the number may range from one to several thousand. Frerichs reports

the case of a woman in whose gall bladder he counted one thousand nine hundred and fifty calculi. Dunlap counted two thousand and eleven in the gali bladder of a woman ninety-four years of age; Morgagni reports having found three thousand in a gall bladder; Hoffman three thousand six hundred and forty-six, while Otto counted the astonishing number of seven thousand eight hundred and two stones in one gall bladder.

The shape of gall stones varies from ovoid to polyhedral, the edges of the latter being generally ground off by attrition with neighboring stones. The specific gravity of gall stones depends upon their moist or dry condition. Fresh stones are heavier than

water, while dry ones are lighter and will float on the surface of water, as these do which I show you. Whether or not gall stones float in the bile, has not been positively determined. They probably do not. The specific gravity of the bile ranged from 10.26 to 10.46, while that of fresh gall stones was 10.27 to 15.80; and, according to Batillat, as reported by French, as high as 19.66. We might infer from this that gall stones do not float in the bile, though it is barely probable that pure cholesterine stones do, on account of their lighter specific gravity. The color of gall stones

is as varied as their size or shape, and may be black, brown, yellow, greenish or white.

Most gall stones are soft and pliable, especially those containing a large amount of cholesterine; but those containing a greater proportion of lime are harder.

Gall stones are generally composed of different chemical constituents, but are sometimes homogeneous. We find them composed of a nucleus, body and crust, as is shown in the specimens I have here. The nucleus is brown or black, and consists of lime and bile pigment, but in rare cases may be some foreign substance or parasite that has found its way into the gall bladder or bile duct. The body or middle zone is composed mostly of cholesterine and arranged in a radiate form, as you perceive in the specimens before you.

The crust is harder than the other parts and usually consists of lime mixed with cholesterine and bile pigment.

ETIOLOGY.-A few words as to the causes of gall stones may not be out of place here.

The causes are generally admitted to be local and constitutional, local causes being mostly instrumental in their origin. Anything producing a chemical change in the bile, causing a precipitation of any of its ingredients, would be instrumental in the formation of gall stones. An acid condition of the bile, interfering with the solubility of the bile pigment, would be favorable for the development of gall stones. Partial decomposition, due to a putrid ferment absorbed by the intestines, as suggested by Dr. Thudichum, may bring about a change in the chemical constituents, lead to a deposit, and thus originate gall stones. Sometimes particles of mucous or a blood corpuscle may be the

nucleus around which calculi form. A globule of mercury has been discovered as the nucleus of a gall stone.

Age seems to play a prominent part in the etiology of gall stones, as the great majority of cases occur in those of advanced age. Out of 395 cases analyzed by Hein, only fifteen were in persons under twenty years of age. Some writers give as an explanation of this phenomenon the fact that in old persons there is an excess of cholesterine in the bile, due to a greater waste of nerve tissue, and this is substantiated to a certain extent by the great predominance of cholesterine in the gall stones of such persons.

SEX. With regard to sex, it has been pretty thoroughly demonstrated that females are more subject to gall stones than males. In Hein's collection sixty-nine per cent. were females, and in the eleven cases reported to the State Medical Society in 1878, by Dr. G. W. Kemper, of Muncie, Ind., eight were females and three males, or a proportion of nearly three to one in favor of females. Durand Fardel, as reported in Ziemesen, gives a table of 230 cases, in which 142 were women and 88 men, or 62 per cent. in favor of women, It is a question of considerable interest why it is that women are more subject to gall stones than men. Hein, Durand Fardel, Fanconneau, Dufresne and others, from their observing the occurrence of calculi in women between the ages of thirty-five and fifty, have attributed it to some changes going on in the sexual functions of these women. But a still further demonstration of this fact will have to be made before it can be accepted as a satisfactory explanation of the phenomenon. It is urged by some that the sedentary habits of women, and the injudicious use of corsets, which contracts the region of the liver, and thereby producing stagnation in the bile, are predisposing causes to the formation of gall stones. This theory is certainly very plausible, but not entirely satisfactory. Whether or not climate, soil and condition of life play any part in the formation of gall stones has yet to be demonstrated, though strong evidence has been adduced to prove that drinking-water, especially that containing large quantities of lime, has been a prolific cause of gall stones.

Heredity has not been proved to play an active part in the etiology of gall stones, though Fanconneau and Dufresne advocate such a theory.

Corpulent people are more subject to gall stones than lean persons, and persons of sedentary habits than those who lead active lives; and as corpulent persons are generally sendentary in their habits, on account of the extra fatigue occasioned by active exercise, we can readily understand why there is a greater tendency to stagnation of the bile in these cases and the consequent precipitation of nucleus for biliary calculi. I do not deem it necessary, nor would the limited scope of this paper permit me, to enter into a detailed account of the pathology and pathological anatomy of the parts involved by the presence of gall stones. There can be no doubt that these stones are always formed in the gall bladder and bile ducts, and when found elsewhere, they have traveled through inflammatory and ulcerative processes to the spots in which they have been discovered. When small or gravelly, these stones find a ready exit through the natural channels into the duodenum, and their passage is attended with very little pain or inconvenience to the patient. But when large, they may become impacted in either of the ducts, and lead to serious and even fatal consequences. Impaction of the cystic duct is usually followed by jaundice, and where the impaction is permanent, total obliteration of the gall bladder may follow, as in the case reported by Dr. Kemper; and this destruction of the gall bladder may not necessarily be fatal, though in the majority of cases cholæmia supervenes before this condition occurs, and death terminates the disease. Impaction of the hepatic duct is more serious than impaction of cystic, and when permanent is almost always fatal, unless the suppurative process establishes another means of communication with the gall bladder and intestines, as sometimes happens. Impaction of the ductus commune is always followed by icteric symptoms, and when permanent impaction takes place, death follows, unless, as in the preceding case, nature establishes fistulous communications with the intestines. Gall stones may exist in the liver and gall bladder without causing any perceptible injury or inconvenience to the patient, as has been demonstrated by post mortem ex. aminations, and this is in part accounted for by the very slight sensibility of these organs, as some writers maintain; but that the ducts leading from these organs to the intestines are endowed with a hypersensitive condition, is only too truly demonstrated by the

pains and agonizing cries of the victims to gall stones. In the great majority of cases, after a certain period of retention, these calculi, acting as any other foreign body, set up the inflammatory process in the liver or walls of the gall bladder or bile ducts, and this inflammation, extending to the adjacent structures, generally brings about adhesions that effectually protects the cavities of the body from the intrusion of the inflammatory products. And here let me remark how beautifully and carefully nature operates for the best interests of its children, generally seeking those outlets' for the discharge of the inflammatory products that are least hurtful to them. These fistulous openings occur in about the following order: First, external or cutaneous being the most frequent; secondly, intestinal; thirdly, gastric; fourthly, genito-urinary; fifthly, fistulous communications with the bronchial tubes; sixth, in extremely rare cases into the portal vein; and lastly, but not as rarely as that into the portal vein, direct fistulous openings into the abdominal cavity. Inasmuch as the case I have to report comes under the first class of biliary fistula, I will devote a few words to the consideration of the pathology of external or cutaneous biliary fistula.

Except those cases of fistula caused by wounds in the biliary passages, cutaneous biliary fistula are nearly always caused by gall stones. According to Von Schueppel, in Ziemssen, these fistula are formed in two ways: either the ulcerative process, which starts from the gall bladder, or a dilated bile duct extends to the adherent abdominal walls, until the external skin finally ruptures, or the gall bladder, or one of the bile ducts first experiences an immoderate distension by the accumulations of bile and fluid inflammatory products, and then ruptures externally, or they are opened with the knife, under the erroneous impression that we have to deal with an abscess of the liver.

As to the position of these openings, no fixed rule can be given. Fistulous openings may appear at any point in the abdominal walls, to the right of the median line, though cases are reported where openings have occurred to the left of the median line. These openings vary in number from one to fifteen, as in the case reported below, and I believe there is no other cure recorded with as many openings-at least, I have failed to find the