paratively rare, the connective tissue of the liver is increased, and a calculous biliary cirrhosis results. It is very ficult, in many of these cases of cirrhosis, to exclude the possibility of their being caused by other toxins; alcohol, for in stance.
[For the notes of the following, ease I am indebted to Dr. Dwyer. W. 11., aged (33, was taken ill with symptoms of bil iary obstruction about two years and a half previous to death. I-Ind pain, jaun dice, delirium, and anorexia during this A calculus in the common bile-duct will, after awhile, produce distension and thickening of the wall of the duct. It sometimes floats in a cavity, often in the ampulla of Yater, acting as a ball-valve, thus causing intermittent or remittent jaundice.
The enlargement of the bile-ducts may extend backward to the smaller radicals. The hepatic cells become deeply stained with bile. In some eases, which are com attack from which be recovered in two weeks.
A year or so afterward he had another attaelt somewhat similar, but symptoms were not so severe. He recovered par tially and was discharged in about five weeks. Shortly afterward the patient began to have chills and became ea eheetie. Chills became more frequent• and severe about two months before death, thomtli there was little or no jaundice up till a few days before the end.
Diagnosis of passage of gall-stone was made at first attack, and at a second at tack ulceration of stone into duodenum with development of suppurative cholan gitis. (See illustrations. The colored plate shows the normal gall-bladder, but turned upward to correspond with the position shown in the half-tone cut, on page 123.) He had, throughout the last attack, irregular rises of tempera ture. J. E. Treatment.—PREVENTIVE.—The par tial or complete stagnation of bile in the gall-bladder and ducts is the principal, if not the only, predisposing cause of the formation of calculi. Any means, there
fore, which will increase the watery con stituent of the bile and render the flow more rapid will be of value as a pro phylactic agent. Means whereby the cir culation is stimulated will also be of service. The emptying of the gall-blad der and ducts may be brought about by exercise and by internal medication. Horseback and bicycle-riding are to be especially' recommended, as well as tennis and lawn bowls and so forth. The occa sional administration of calomel followed by a saline cathartic is one of the most effectual methods of emptying the gall bladder. The taking of large quantities of water, especially of Carlsbad or other alkaline water, an hour or so before meals is of service, as the liver is, in that way, flushed out, and the bile flows more freely.
Ox-bile used internally in biliary colic. The bile is decolorized to get rid of the toxic coloring, matter (especially rubin), and then sterilized at 220° to 222° F.; 3 ounces of hile produce 2 V, drachms of the extract. Of this latter 3 grains in pill or capsules are given twice a day after meals. They may be con tinued for years, or given intermittently, whenever there is any sig,n of colic. Re sults obtained in several cases have been brilliant. It cannot. however, be regarded as a certain preventive of colic, since if the gall-bladdcr is full of stones it does not cause them to disappear, though it prevents the formation of fresh calculi. The treatment is recommended after operations for the evacuation of calculi to prevent relapses. Gautier (Rev. Med. de la Suisse Rom., June 20, '98).
On the question of diet there is much difference of opinion. It is, however, safe to say that starchy and saccharin foods, which render the bile more dense, are to be avoided.