CHOLELITHIASIS. — From Gr., xo2,r , bile, and 2,,t0tccgt;, from 2.;,0o;, stone.
Definition.—The term "cholelithiasis" is applied to that condition which re sults from the precipitation of choles terin from bile and from the combina tion of bilirubin ancl lime, which form an insoluble compound. These two, cholesterin and bilirubin-calcium, make up nearly the whole mass of the biliary calculi. The calculi are of varying size and density.
The presence of concretions in the biliary passages may produce obstruction of the ducts, ulceration and perforation of the walls, and the formation of fis tulous channels. The process may be accompanied by cholangitis, cholecys titis, and perihepatic abscess. Obstruc tive jaundice, biliary cirrhosis, and in testinal obstruction may be directly caused by gall-stones, and can be dis cussed under the head of "cholelithiasis." Physical Properties ; Varieties.—Bil iary calculi vary in size from that of a grain of sand to that of an English walnut or be even larger.
Case in which a conglomeration of cal culi formed a mass about the size and shape of a pear, which was passed during life. The patient was a female, 60 years of age. Case also mentioned, described by Fiedler, of a stone consisting of three pieces which was over twelve inches in length and weighed forty-six grammes. It completely filled the gall-bladder. Krauss (On "Gall-stones," p. 11).
The sn-iallest (gall-sand) are dark in color and are wholly made up of bili rubin-calcium. Not infrequently a large number of small calculi, angular, fa cetted, and grayish in color, are found in the gall-bladder or in a sac opening into the common duct.
The larger ones are dark brown or of a dark-yellowish color, depending on the amount of bilirubin-calcium which exists in the outer layer.
When calculi are small they are usu ally very numerous. In one case over two thousand were removed.
[Mayo Robson has reported a case in which 72S gall-stones were removed from the gall-bladder and dilated ducts of a, woman aged 54. Dr. Peters has wit nessed a ease (unpublished) in which 563 gall-stones were removed from a dis tended gall-bladder. J. E. GRAHAM.] The larger ones exist singly or in small numbers. The shape depends on the number present. When large and single they are round or more frequently oval, but when a number exist together in the gall-bladder or in a sacculated enlargement of the bile-duct they are facetted, the result of attrition. Occa
sionally a single stone is found facetted: an indication that others have already passed through the ducts. Classification.— Biliary calculi have been classified according to the propor tionate amount of their two principal constituents: cholesterin and bilirubin calcium. They may be divided into three principal classes:— 1. Pure cholesterin.
2. Mixed cholesterin and bilirubin calcium.
3. Pure bilirubin-calcium.
The mixed variety is altogether the most frequently met with, and choles terin is the principal constituent.
Naunyn, whose classification is now generally adopted, makes the following division:— 1. Pure cholesterin.
2. Laminated cholesterin.
3. The common gall-bladder stones.
4. Mixed bilirubin-calcium.
5. Pure bilirubin-calcium.
6. Rarer forms.
The common gall-bladder stones are altogether the most frequent. The larger ones are about the size of a cherry, and they may be of a lemon or brownish yellow color. When fractured, the sur face presents a crystalline, glistening ap pearance, in which the light-yellowish color predominates. The cholesterin is arranged in layers between which bili rubin-calcinm exists in greater or less quantities. The nucleus is often com posed of bilirubin-calcium; broken-down epithelial cells, bacteria, and foreign bodies have been found in the centre. When very numerous, calculi in the gall bladder are often of a light-grayish color, and consist of an outer shell and a soft nucleus.
The pigmentary, or bilirubin-calcium calculi gall-sand, are small, and bre found in greater numbers than the cholesterin and mixed varieties. They are sometimes found in the intrahepatic ducts, and appear to be the result of a catarrhal cholangitis. A rare variety of gall-stones, composed principally of calcium carbonate, is occasionally found.
Besides the constituents already men tioned, the following elements and com pounds have occasionally been noted: Calcium sulphate and phosphate; cop per and iron combined with bilirubin calcium. Globules of mercury were found by Ferrictis.
Symptoms.—The symptoms of gall stones may be studied under three heads: 1. Those produced by the passage, of calculi through the natural channels. 2. Those produced by gall-stones when they have found their way outside of the gall-bladder and ducts. 3. Complica tions and sequelie.