Gall-stones and diseases of the bile-ducts . of the common duct wasequal to a pigeons egg, but I have found persistentjaundice of eighteen months standing due to a gall-stone not larger than a cherry-stone, and of the sameshape, impacted in the ampulla. The specimen re-presented in Fig. 29 is instructive in this is a fair assumption that a gall-stone the size of acherry-stone represents the maximum dimensions ofa stone capable of being extruded through theampulla. In this connection it must not be for-gotten that some of the large openings in theduodenum supposed to be normal ostia
Gall-stones and diseases of the bile-ducts . of the common duct wasequal to a pigeons egg, but I have found persistentjaundice of eighteen months standing due to a gall-stone not larger than a cherry-stone, and of the sameshape, impacted in the ampulla. The specimen re-presented in Fig. 29 is instructive in this is a fair assumption that a gall-stone the size of acherry-stone represents the maximum dimensions ofa stone capable of being extruded through theampulla. In this connection it must not be for-gotten that some of the large openings in theduodenum supposed to be normal ostia are choledocho-duodenal fistulas (see p. 84). 96 DISEASES OF THE BILE-DUCTS Gull-stones large enough to block the small intes-tine find their way into the intestines through open-ings formed by ulceration in the wall of the gall-bladder and the wall of the duodenum, which isadherent to it, in consequence of inflammation. Themode by which the adventitious opening arises wasdiscussed in Chap. V. No positive statement is possible regarding the. Fig. 31.—A gall-stone which blocked the ileum six inches fromthe ileo-csecal valve in a woman aged seventy-six was performed, and the stone was manipulatedthrough the ileo-csecal opening into the ceecum. size of a gall-stone necessary to block the small in-testine, for the lumen of the intestine varies indiameter in different persons. Moreover, the lumenof the small intestine narrows from the duodenumto its termination at the ileo-csecal valve ; hence astone which would be impacted in the terminal seg-ment of the ileum would traverse the jejunum with-out much difficulty. For example, the calculusrepresented in Fig. 31 I found firmly impacted in OBSTRUCTION FROM GALL-STONES 97 the ileum six inches from the ileo-caecal valve in awoman aged seventy-nine years. With care I suc-ceeded in overcoming the muscular spasm andgently pushed the stone along the ileum and throughthe ileo-caecal aperture. The patient recovered
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