Gall-stones and diseases of the bile-ducts . rmation are soft explains their curious shapewhen occupying the intra-hepatic ducts (see p. 91). The formation of gall-stones is more complexthan would appear at first sight. For example, purecholesterin stones can only form in a gall-bladderwhen the cystic duct is so completely obstructedthat no bile enters the gall-bladder. Then, as Naunyn so carefully relates, when thecholesterin nucleus of a gall-stone is coated withlayers of bilirubin-calcium and biliverdin-calcium, itmay, if no bile runs into the gall-bladder, becomecoated with cholesterin, an
Gall-stones and diseases of the bile-ducts . rmation are soft explains their curious shapewhen occupying the intra-hepatic ducts (see p. 91). The formation of gall-stones is more complexthan would appear at first sight. For example, purecholesterin stones can only form in a gall-bladderwhen the cystic duct is so completely obstructedthat no bile enters the gall-bladder. Then, as Naunyn so carefully relates, when thecholesterin nucleus of a gall-stone is coated withlayers of bilirubin-calcium and biliverdin-calcium, itmay, if no bile runs into the gall-bladder, becomecoated with cholesterin, and under favourable con-ditions the cholesterin may permeate the calculusand crystallise, and whilst the cholesterin is thuspermeating the calculus through favouring cracksand fissures the bilirubin-calcium is dissolved out andfinally replaced. Thus a gall-stone primarily com- 58 DISEASES OF THE BILE-DUCTS posed of laminae is transformed into a pure chole-sterin calculus with a crystalline structure (secondarycrystallisation of cholesterin).. •WETAU Fig. 20.—A gall-bladder tightly filled with calculi. A portionof the wall has been cut away to show them arranged likethe pieces in a mosaic with mucus for cement. (Museum ofthe Charing Cross Hospital.) This observation is of importance because theabsence of surface crystallisation on the gall-stone LIBRARY OF Ti-SCHOOL OF MEDICINEYALE UNIVERSITY GALL-STONES 59 shows that their growth has not been brought aboutby the deposition in crystals of the cholesterin heldin solution by the bile. The time required for theformation of gall-stones has been variously evidence supports the view that itrequires six months to form a well-stratified biliarycalculus (Mignot). Calculi are probably formed inbatches, and it is possible that the calculi in a gall-bladder may be of the same age and due to the sameattack of cholecystitis. This would explain the factthat the calculi in any one gall-bladder are of thesame class and
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