If these are in the common or hepatic ducts they will almost certainly cause jaundice, and then the diet that has already been recommended for that condition will be appropriate.

As far as we know no article of diet has any influence upon the formation of gall-stones or their absorption, but it stands to reason that if the patient is eating too rich food or too much food he should be advised to take plain ordinary food. If once a gall-stone, however minute, has formed, stagnation of bile will favour its increase in size. We know that the taking of food into the stomach leads to a flow of bile, and therefore patients liable to gall-stones should not go long without meals; at least four meals a day should be taken and these at regular intervals. As few people take food during the night, the stagnation of the biliary flow is greatest at that time. On rising, therefore, breakfast should be taken early and should be abundant. It is said that, even apart from jaundice, patients suffering from gall-stones take fats with difficulty, therefore butter is sometimes forbidden; but there is no direct evidence that this is necessary.

There is no doubt that many persons who pass gall-stones, or who suffer from them, are benefited by going to Carlsbad, where the patients before breakfast drink warm water, the chief constituent of which is sodium sulphate. It is improbable that this acts on the bile, indeed how it does good is not known, but it is supposed to aid the expulsion of the stone by increasing the peristaltic movement of the bile-duct and duodenum. Be that as it may, the success attained at Carlsbad suggests that similar warm water may be taken at home. Carlsbad salts can be bought and dissolved in water. A close imitation of Carlsbad water is made by dissolving 22 grains of sodium sulphate, 12 grains of sodium bicarbonate, and 10 grains of sodium chloride in a pint of water. Twelve fluid ounces of warm Carlsbad water should be drunk before breakfast, 3 oz. each quarter of an hour. Some patients can take double this quantity, and some apparently improve by drinking an equal amount of warm water.

There is much divergence of opinion as to whether olive oil is useful in aiding the expulsion or solution of gall-stones. A gall-stone placed in olive oil at the temperature of the body-slowly loses weight, because cholesterine, the chief constituent of gall-stones, is soluble in olive oil. It is the oleic acid, of which olive oil contains 72 per cent, that is the chief agent in effecting this solution, and it is suggested that when olive oil is taken by the mouth, the oleic acid is excreted by the liver or the mucous membrane of the biliary passages, and so slowly diminishes the size of the gall-stone. To some extent also the expulsion of the stone may be aided, because the intestinal peristalsis set up by the oil extends to the bile-ducts. This method of treatment is well worth a trial, for many patients say they derive considerable benefit from it. From 2-8 fluid oz. of the oil should be taken daily. The best way is to drink it after meals. Some persons do not mind doing this, but to many it is very disagreeable. The best method of flavouring the oil is to add a few grains of menthol and a little brandy to each 8 oz. of oil. Some of it may be mashed up with potatoes, salad, or fish. Pure olive oil should be used, as it is often adulterated, especially with sesame oil and cotton-seed oil, for the pure oil is expensive. If olive oil causes so much nausea that it is impossible to take it, seven grains of oleic acid - best prescribed in capsules - may be given two or three times a day. A few patients who suffer from gall-stones find they cannot take butter or the fat of meat. This is what we should expect if they are jaundiced, but if they are not it is difficult to understand why they should not take fats as easily as in health. It must be remembered that if medical treatment does not relieve the symptoms of gall-stones very considerable risk is run by leaving them. A study of a series of cases of gall-stones and a series of cases of malignant disease of the biliary passages leaves no doubt that gall-stones are a serious cause of malignant disease of the gall-bladder and biliary passages. Probably somewhere between 15 and 20 per cent of persons with gall-stones develop malignant disease of the gall-bladder or biliary passages as a result of the gall-stones. Further, about 4 per cent of all persons with gall-stones sooner or later suffer from infective cholangitis, empyaema of the gall-bladder, sloughing of the gall-bladder, or abscesses in the liver.