On the causation of cholelithiasis : an introduction to a discussion in the Section of Medicine at the Annual Meeting of the British Medical Association, Montreal, 1897 / by William Hunter.

  • Hunter, William, 1861-1937.
Date:
1897
Catalogue details

Licence: Public Domain Mark

Credit: On the causation of cholelithiasis : an introduction to a discussion in the Section of Medicine at the Annual Meeting of the British Medical Association, Montreal, 1897 / by William Hunter. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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    by Brockbank. The formation of vincons maaseB by the mncouB membrane of gall bladde-, consisting almost solely of pure choleaterin, I have also been able to observe; these viscous masses bv pressure against one another and adjacent gall stones already possessing the characteristic shape of gall stones. The important conclusion is thus led up to, that the cholesterin which goes to form gall stones has never really been in solution in the bile, but has been in a more or less solid viscous form from the beginning, formed as a product of degeneration of the epithelium of bile passages. 2. With regard to the insoluble compound, bilirubin calcium. In normal bile these two constituents are not combined. Nor can they be made to combine by any mere concentration of bile. Bilirubin itself may deposit under such circumstances, but not in combination with calcium. Nor can the two be made to combine by any mere excess of lime, at least in the first instance. But if further excess be added a deposit of bilirubin calcium finally takes place, till finally the whole of the bilirubin is thus precipitated. There appear then to be substances in the bile which prevent the precipitation of bili- rubin calcium, even when the amount of lime is considerably increased (Naunyn). The bile salts seem to exercise some such function. Thus it only requires the addition of a few drops of limewater to a weak ammoniacal solution of bilirubin to precipitate the whole of the latter as bilirubin calcium (Naunyn). But if such a solution contains 2^ per cent, of glychocolate of soda, precipitation only begins when five times the quantity of limewater is added. The lime is seized upon by the bile acid. It is probable then that a certain re- action of bile is necessary for the formation of this bilirubin calcium compound. Apart from mere reactioUj or proportion of bile salts present, there is another observation of interest in this relation, namely, that just as egg albumen favours the precipitation of calcium carbonate from solutions of bile salts, so also egg albumen favours the precipitation of bilirubin calcium (Naunyn). This suggests, then, that the presence of albumen in the bile passages and gall bladder may favour the formation of bilirubin calcium concretions. Albumen derived from the disintegration of epithelium, that is catarrh which promotes such disintegration, is thus in all probability the factor which determines the precipitation of bilirubin calcium within the bile passages and gall bladden Catarrh of Gali> Bladder and Bilk Ducts asJthe Lmmkdiatk Cause of Cholelithiasis. It thus appears that the conditions leading to increased for- mation and deposition of cholesterin in solid form, and to the precipitation of the insoluble body—bilirubin calcium- are es^entially local; andare of the kind—increased epithelial degeneration and presence of albumen—tliat prevail in a special degree in catarihal and inflammatory conditions of the lining membrane of gall bladder and bile ducts. I have now to consider what it is that sets up this catarrh. Among the various factors which have been held respon- sible for the formation of gall stones-the influence of age, sex, heredity, gout, rheumatism, etc., the only one whose influence is undoubted is stagnation of bile. In the list of conditions! have noted under “general etiology” it will be seen that the degree to which any one of them favours the inci-