PASSAGE OF GALL-STONES OUTSIDE THE ORDINARY CHANNELS.—The synap toms will depend upon the course taken by the calculus. In some instances the stone passes through the ulcerated wall, and, owing to the presence of pyogenic organisms, an abscess forms, which gives rise to symptoms similar to those of ap pendicitis; pain, high temperature, local ized tenderness, and swelling. The ab scess may open into a neighboring cav ity, most frequently at the intestines, or it may extend outwardly. In other cases the stone may form a fistula with very few localized or general symptoms. Large calculi have been passed by pa tients which from their size must have made their way by ulceration from the gall-bladder into the intestines, although no history could be obtained tending to indicate that such a process had taken place. As a rule, however, there is more or less local pain, tenderness, and swell ing.
The broncho-biliary fistula is accom panied by severe coughing and the ex pectoration of bile. Gall-stones have been expectorated in some cases. I have reported a case in which expectoration of bile was present three weeks and then ceased to return; after ten years' time calculi were found in the common duct.
Sudden death has been witnessed in a case in which rupture took place into the pericardium.
Dilatation of the stomach due to in flammatory adhesions, closing the py lorus, or to the presence of a gall-stone making its way through the pylorus is attended by the usual symptoms of such a condition. Calculi have been expelled from the stomach, which have either found their way into that viscus directly, or, as is more commonly the case, have been regurgitated from the duodenum.
[The following case presents some pe culiar features: The patient had been -under the writer's observation for many years previous to his death. Fifteen years before Ile suffered from 'binary colic and obstructive jaundice. A hard mass remained, which was thought at the time to be eaneer. The patient recovered and the tumor disappeared. He was after ward troubled with a pectiliar form of diarrlwea: awakening toward morning lie had two or three watery passages.
which -weakened him very much. These attacks toward the close of his life be came more frequent and were very dis tressing. The cause was supposed to be want of tone in the pylorus, -which allowed undigested food to pass into the bowel. Very little of the latter, how ever. \vas noticed in the discharges. The following condition was folind at the au topsy: There were many old inflamma tory adhesions in the region of the g,a11 bladder. The latter was much contracted and dislocated. The eommon duct was very small.
There was a large secular dilatation of the duodenum, whieli formed a pouch four inches from the pylorns. The pouch was continuous with the intestine below by a valve-like orifice about the size of the pylorus. This was probably formed in the passage of the gall-stones fifteen years before, and it is probable that the contents of the stomach aecumulated in the pouch and were at imes discharged, producing the sudden attacks of diar rhwa. I am indebted to Drs. Powell and: Anderson for the post-mortem notes. J. E. GRAHAM.] (Case has not been pub lished.) The arrest of calculi in the intestines produces at once a series of very grave symptoms of gall-stone ileus. The most prominent are sudden and severe pain; nausea; vomiting; rapid, quick pulse; with other symptoms of collapse. The mortality in such cases is very high. The. lower part of the jejunum is the usual seat of the obstruction. When the stone is arrested in the duodenum, the gastric symptoms are much more marked, and. when in the lower part of the small in testine, indican may be found in excess in the urine.
Fatal ease of gall-stone ileus. The pa tient bad for a long time suffered from attacks of pain, especially when tired from standing. _At the operation the stone was found, after a long search, in the small intestine and removed. It was olive shaped and weighed 400 grains. Death from collapse tool: plaee two days after the operation. Bridon (Annals of Surg., Jan., '97).