Diagnosis.—In acute catarrhal cho langitis the diagnosis is usually easily made from the digestive disturbance and gradual onset of the jaundice. Gall stones are excluded by the absence of colic and the fact that the jaundice is not of sudden development. In catar rhal cholecystitis there is enlargement of the gall-bladder, which may be palpa ble as a pyriform tumor adherent to the liver and rising and falling with respira tion. Not infrequently a tongue-like lobe of the liver is mistaken for a dis tended gall-bladder. So may also a movable kidney; it is nsually more easily displaced, and is not attached to the liver. Instead of being smooth, rounded, and elastic, the distended gall-bladder may, from inflammatory thick-ening, ap pear more like a solid tumor and be mis taken for cancer in this situation, but cancer is usually associated with jaun dice and cachexia. Echinococcic cysts have also to be excluded; aspiration may be necessary to do so. The history and shape of the tumor may be sufficient to differentiate between the two conditions.
The diagnosis of suppurative cholan gitis is to be made by a history of gall stones, the occurrence of a septic condi tion with enlargement and tenderness of the liver, and the existence of leucocyto sis. There is progressive loss of flesh and strength. The duration rarely exceeds a few weeks, the cases lasting months and ultimately recovering being most prob ably cases of chronic catarrhal cholan gitis due to obstruction, and causing in termittent hepatic fever.
Etiology.—Inflammation of the bile passages usually results from extension of an inflammatory process from the duodenum, and is, in the majority of cases, associated with gall-stones. The duodenal catarrh that precedes the cho langitis usually follows acute indigestion. The young are most, susceptible to it.
but it may occur at any age. It occurs also as the result of exposure to cold, chills, malaria, typhoid fever, pneumo nia, and in the course of Bright's disease, chronic heart disease, emphysema, etc. It may occur in the course of any or ganic disease of the liver, as inflam mation, cancer, and hydatids. Chronic catarrhal cholangitis may possibly be a sequel to the acute. It is always due to obstruction of the common bile-duct from gall-stones, stricture, pressure from without, etc. The obstruction may be complete, in which case the ducts are greatly dilated and filled with clear, watery fluid similar to that of dropsy of the gall-bladder. If the obstruction is incomplete, there is less dilatation of the ducts, and, as some bile filters through, their contents are bile-stained and tur bid. The gall-bladder is not much di lated in these cases, obstruction of the cystic duct being necessary to cause great dilatation of it. Gall-stones are usually
found in it.
Suppurative cholangitis is usually as sociated with gall-stones, less frequently with echinococci and round worms. The mucosa, injured by such foreign bodies, becomes more susceptible to invasion by pyogenic organisms, and these are pres ent normally in the intestines and in the lowest part of the common bile-duct.
Morbid Anatomy.—In acute catarrhal cholangitis the lower part of the com mon bile-duct is usually chiefly, and may be the only part, afTected. The inflam mation may extend to its larger branches. Post-mortem evidences are slight, as red ; ness and swelling disappear after death. A plug of inspissated mucus may fill the diverticrilum of Vater and completely obstruct the flow of bile. The gall bladder, when affected, contains a more or less viscid mucous secretion; if there is obstruction of the cystic duct, the bladder becomes distended with fluid, of which it may contain one or more pints, usually thin and without bile. The walls of the gall-bladder are thin and shining; but, if the obstruction persist, they may become much thickened.
In suppurative angiocholitis the com mon duct becomes greatly dilated and its walls much thickened. Similar changes occur in the gall-bladder. Both are dis tended with pus. -Ulceration may occur and perforation into the stomach, colon, or duodenum, or even into the urinary or respiratory tract. The intrahepatic bile-ducts may be distended with pus,— which is usually bile-stained. The sup purative process may extend to the hepatic substance, resulting in abscess formation, or to the portal vein, and pylephlebitis result.
The bacteria present in these inflam matory processes are very various. The bacillus coli comrnunis probably plays the most important part, but staphylococci and streptococci are also common, as they are all present in the duodenum in health. The pnenmococcus and the typhoid bacillus may be the active agents.
Treatment.—This consists in measures to relieve the gastro-duoclenal catarrh. Plenty of liquids should be taken, espe cially the alkaline mineral waters. The bowels should be moved freely, but not immoderately, by the use of calomel fol lowed by salines, such as Carlsbad salts, phosphate of soda, etc. Bicarbonate of soda, with bismuth, may prove useful for the gastric disturbance. Such antiseptics as resorcin, guniacol-carbonate, and sa licylate of bismuth are useful. A large cold, rectal enema may be given daily; it is said to stimulate contraction of the gall-bladder ancl ducts and thus promote expulsion of the mucus that is obstruct ing the escape of bile. The water is to be retained so as to furnish more liquid for excretion.. but it cannot effect that object better than water taken by the stomach.