1. The microbic theory of gall-stones which was promulgated ten years ago is now an established fact.
2. It is probable that the micro-organ isms favor the precipitation of certain elements of the bile, but the microbes cause a catarrh, which may not be recog nized clinically. The degeneration of the epithelial cells produces the cholesterin and Bine. The latter combines with bili ruhin to form the insoluble bilirubin calcium.
3. Lithiasis is a result of the infection of the whole biliary tract or of the gall bladder alone.
4. Calculi may be divided into two classes: those produced by the colon and those by the typhoid bacilli. The colon bacillus is the most frequent cause. Fournier (Origine Microbienne de la Lithiase Biliaire, Paris, '96).
Cholesterin is not wholly of local origin as claimed by Natinyn. R. H. Chittenden (Med. News, May, '97).
Conclusions arrived at, largery from experiments upon animals:— 1. The presence of aseptic foreign bod ies in the gall-bladder does not produce inflammation and does not seem to affect its function, if the cystic duct remain patent. There is no precipitation of cho lesterin when the bile remains clear and free from microbes.
2. Bile stagnant in an aseptic gall bladder has no tendency to precipitate.
3. There is greater tendency to pre cipitation when the infection is from an attenuated, than from a strong, virus. R. Mignot (These de Paris, '96).
Naunyn's theory that gall-stones are the result of catarrhal inflammation of the lining mucous membranes not ac cepted. In most cases they result from a decomposition of the bile into simpler substances, such as are produced more particularly during the process of so called spontaneous decomposition after its removal from the body.
Those who look at the formation of gall-stones as simply the result of local changes, and do not study the general constitutional conditions which give rise to them are like those of whom Stro meyer speaks: "They hear the little grass grow while the thunder rolls un observed in the upper ether." J. L. IV. Thudicum (Med. Press and Circular, vol. lxiv, 20S-210, '97).
Epithelial degeneration and the pres ence of albumin are purely of a local character and are the result of catarrhal and other inflammations of the gall-blad der and bile-ducts. TWO etiological fac tors recognized of catarrh: 1. Infection of the gall-bladder with micro-organisms, the two most frequently found being bacillus coli communis and the typhoid bacillus. 2. Excretion of irritant sub stances throngh the bile which cau-se a catarrh of the intrahepatic ducts in which the bilirubin-calcinm calculi are formed. These latter may afterward find their way into the gall-bladder. The lime, which is rapidly formed in the ca tarrhal process, combines with the bili rubin to form a substance insoluble in bile. William Hunter (Brit. Med. Jour., Oct. 30, '97).
Experimental formation of gall-stones. Three drops of a culture of typhoid ba cilli were injected in the gall-bladder of a rabbit. At the autopsy, six weeks afterward, two small calculi about the size of grains of wheat were found in the gall-bladder. They were made up of a whitish kernel inclosed in a dark-colored shell. A pure culture of typhoid bacilli
was made from the nucleus of one of them. Gilbert and Fournier (Deutsche med. Woch., Dec., '97).
Case of formation of gall-stones around sutures allowed to remain in the gall bladder after a cholecystotomy. The gall-bladder was entirely emptied of stones in April, 1S95, and in January, 1S97. several round and oval calculi were found. Sutures formed the nucleus of each. (See colored plate.) John Homans (Surg. Annals, July, '97).
The simple presence of organisms in the gall-bladder does not seem sufficient to set up inflammation of the mucosa nor to produce cholelithiasis. Some other factor, presumably some form of irrita tion, such as traumatism or some hin drance to the proper evacuation of the gall-bladder, is essential. Cushing (Johns Hopkins Hosp. Bull., Aug.-Sept., '99).
Predisposition to gout and rhemnatic disorders regarded as largely concerned in the production of gall-stones. If the bacterium coli commune is a cause, it is on account of its producing- a catarrhal condition of the intestinal tract. W. L. Carr (N. Y. Med. Jour., Apr. 22, '99), Bilirubin-calcium is insoluble in water, and cannot be formed simply by concentrating the bile. It has been found that egg-albumin will aid in the precipitation of bilirubin-calcium from bile. It is probable that albumin may act similarly in pathological processes.
Formation of binary calculi does not take place solely in the gall-bladder. Some are formed in the ramifications of the hepatic duct. Cholesterin and cal cium (bilirubinate of lime), the chief chemical constituents of biliary calculi, come from the mucous membrane of the biliary ducts. Lithogenic catarrhs of the mucous membrane may be excited by microbes (con bacillus, Eberth's bacillus, possibly also by others). Great virulence of the germs is by no means favorable to the formation of concretions. Slight in fections may become developed as soon as there is stagnation of bile. Naunyn (Intern. Med. Congress; Brit. Med. Jour., Sept. 29, 1900).
The formation of bilirubin-calciurn stones, as has been already intimated, takes place in the intrahepatic ducts. Naunyn and others are of opinion that the calcium results from an inflamma tion of the lining membrane of the ducts, from the presence of microbes. It would seem difficult to understand how micro organisms find their way from the duo denum into the smaller bile-ducts, and still more difficult to conceiye of their entering the intrahepatic ducts from the blood without seriously affecting the parenchyma of the liver. As has been already noticed, -William Hunter, of London, is of the opinion that calculi of the intrahepatic ducts is caused, not by micro-organisms, but by toxins ex creted by the liver. The function of the liver as an excretory organ has been amply proyed by Schiff and others, and a catarrhal inflamination from this cause seems reasonable.
Spontaneous fracture of biliary calculi sometimes takes place.
The view that spontaneous fracture might arise from an invasion of microbes expressed by some members. Discussion in the London Pathological Society (Brit. Med. Jour., NOV. 20. '97).