. Diseases of the gall-bladder and bile-ducts, including gall-stones . ety, the whole length of the intes-tinal canal has to be travejsed by the concretions; hencesuch cases are found to be more frequently associated withobstruction than when the fistula is between the gall-bladderand colon, for in the latter case the passage to the anus isaccomplished without difficulty, though occasionally the con-cretions may lodge and cause trouble. When a gall-stone is impacted in the common duct justbefore entering the duodenum, ulceration and perforation ofthe duct are apt to occur, the concretion thus
. Diseases of the gall-bladder and bile-ducts, including gall-stones . ety, the whole length of the intes-tinal canal has to be travejsed by the concretions; hencesuch cases are found to be more frequently associated withobstruction than when the fistula is between the gall-bladderand colon, for in the latter case the passage to the anus isaccomplished without difficulty, though occasionally the con-cretions may lodge and cause trouble. When a gall-stone is impacted in the common duct justbefore entering the duodenum, ulceration and perforation ofthe duct are apt to occur, the concretion thus escaping into * Lancet, 1878, vol. i., p 851. 86 DISEASES OF THE GALL-BLADDER AND BILE-DUCTS the duodenum by an enlargement of the ostium of thecommon bile-duct from ulceration or sloughing. Roth, who has paid special attention to this condition,found it five times in twenty-five cases of biliary fistula. These gall-stones are usually smaller than those causinggall-bladder intestinal fistula, are seldom larger than filberts,and do not often cause intestinal Fig. 23.—Gall-stone in Act of Extrusion into Duodenum,the Edges of the Opening being ulcerated. (No. 2,826, Royal College of Surgeons Museum.) Nearly all the museums have in them examples of gall-bladder duodenal fistula. Specimens Nos. 2,827 and 2,828in the College of Surgeons Museum are good examples. No. 2,826 shows a gall-stone in the act of extrusion, andit will be seen that the margins of the opening are ulceratingto allow of the passage. Death occurred after six weeks ofsuffering (Fig. 23). No. 1,399 in Guys Museum is a specimen of Dr. HaleWhites, showing a gall-bladder duodenal fistula 1 inch fromthe pylorus, large enough to admit the finger; and 33 inches INFLAMMATORY AFFECTIONS 87 above the ileo-csecal valve is a large gall-stone impacted inthe ileum. Nos. 2,261 and 2,262 in St. Bartholomews Museum show-gall-bladder duodenal fistulas.
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