MORBID ANATOMY.—The gall-bladder may be distended with calculi and little change found except erosion of the mu cous membrane, with more or less thick ening and infiltration in places. Chole cystitis and pericholecystitis may cause these changes to be more pronounced. Phlegmonous inflammation of the gall bladder sometimes occurs in acute dis eases.
Calcification of the gall-bladder some times follows ernpyema, in which the mucous membrane may be coated or the whole thickness of the wall may become infiltrated with lime-salts.
Distension of the gall-bladder usually arises from the arrest of calculi in the cystic duct. The contents in uncom plicated cases are largely composed of mucus, more or less bile-stained: hydrops fellew. If at the same time there is an invasion of pyogenic organisms, an em pyema of the gall-bladder results.
Ulceration and perforation sometimes occur, allowing the contents of the gall bladder to pass into the peritoneal cav ity.
Two cases of distension of the gall bladder from flexion of the neck. No gall-stones were found. A. H. Ferguson (Brit. Med. Jour., NOV. 6, '97).
Fatal ease of rupture of the gall-blad der. Patient 26 years of age. The gall stones found their way out of the gall bladder partly by ulceration and partly from expulsion. Some gall-stones and bile-stained fluid were found in the ab domen, together with the results of gen eral peritonitis. A perforation of the rectum, which allowed fteces to pass out, was also discovered at the post-mortem. The perforation thought to have been caused by pressure of gall-bladder stones on the peritoneal coat of the bowel. The patient lived twenty-five days after the rupture of the gall-bladder. Shadbad (St. Petersburger med. 'Woch., Jan., '96).
FISTUL1E.—Gall-stones may pass out through the wall of the gall-bladder or ducts into the surrounding structures, producing fistu12, which may take dif ferent directions.
In hepatico-bronchial fistul a series of cases of this rare form of disease studied by the writer showed that the opening through the diaphragm into the gall-bladder may arise from a distended gall-bladder passing over the anterior border of the liver, or that calculi could find their way by ulceration through the wall of the gall-bladder and ducts, form ing an abscess which may penetrate the convex surface of the liver and the dia phragm. In such cases a cavity is often
formed by- the presence of intrahepatic calculi and of pyogenic organisms. A direct fistnlons opening may take place between the gall-bladder and the stom ach.
Case of obstruction of the pylorus pro duced by a gall-stone and surrounding inflammatory adhesions. There was a direct communication between the gall bladder and stomach, a cystico-stomachal fistula. Monprofit (Bull. de la Soc. d'Anat. de Paris, May, June, '97).
Fistulous openings into the duodenum or through the abdominal walls are •the most common. In the latter case open ings may take place in the right hy pochondrium, near the umbilicus and above the pubes.
Interesting case of biliary fistula into the urinary tract. The post-mortem re vealed a fistula, leading into an abscess and from this into the pelvis of the right kidney, where a large cholesterin calculus was found. Elsner pied. News, Feb. 5, '98).
Courvoisier has reported seven cases of urinary fistulm. Cases of fistula? into the uterus and vagina have also been re porter]. The chronic irritation resulting from the presence of calculi in the gall bladder and ducts may give rise to atrophy or calcification of the gall bladder and to the formation of diver ticula and cicatrices. Thickening of the surrounding tissues is also a common re sult. In 255 autopsies in gall-stone cases given by Courvoisier, atrophy of the gall-bladder was found in 12 1/,, per cent. It is the result of frequent tarrhal inflammation. In such cas,es the gall-stones are found imbedded in the contracted gall-bladder or in diverticula.
The obliteration of the cystic canal, the gall-bladder being aseptic, results in atrophy of the reservoir, the same fIS if it ecmtained foreign bodies more or less irritating. Ariiirmis (This•se (le Paris, '9(1).