Causes

Gall-stones are composed chiefly of cholesterin, which is secreted by the mucous membrane of the gall-bladder and bile-20 ducts. Normally it is kept in solution by the bile salts of sodium and potassium (the taurocholate and glycocholate). Cholesterin is formed in excessive amounts especially when there is catarrhal inflammation of the bile-ducts. The bile salts may be formed in relatively small amounts when the liver is inactive and when sufficient nitrogenous food is not eaten. Obstructions to the flow of bile, even when temporary or partial, predispose to the formation of stones. Sometimes foreign bodies form the nucleus of the concretions. Bile pigments and lime are occasionally ingredients of them. Sedentary habits also predispose to their formation. The claim that has been made that infection of the bile-ducts is essential to the formation of calculi is probably correct.

It is rare that the gall-bladder or ducts contain only one calculus. As a rule, the stones are numerous and of a small or moderate size. Therefore, when their existence has been demonstrated by the occurrence of hepatic colic and jaundice or the discovery of them in the stools, it may be concluded almost with certainty that there are in the gall-bladder many others that will cause trouble in the future. There is no regimen that will cause their solution, but it is possible to prevent their growth and multiplication.

Treatment

It is extremely important that water be drunk freely to make the bile copious and thin. It has been thought that the prolonged use of hard water increased the liability to the formation of gall-stones containing lime, but there is no adequate proof of this. Saline alkaline spring-water, such as that of Carlsbad, is particularly beneficial. Many patients have been observed, while under treatment at Carlsbad, to pass stones with comparatively little discomfort. Carlsbad water and Carlsbad salts are extensively used in all parts of the world for the treatment of this affection. Wiesbaden, Ems, Vichy, Neuenahr, Marienbad, Kissingen, and Homburg are the chief European springs that are believed to be helpful. Saratoga, West Baden, and similar American spring-waters are also of value. Carlsbad salts are best given in hot water before breakfast. Before each of the other meals, one or two glasses of hot water should be drunk. It is generally believed that alcoholic beverages should be avoided or used very sparingly. Tea and coffee must be employed only in small amounts; if there is much indigestion they should be forbidden.

An abstemious diet is of more importance than a diet limited in character. The use of foods that prove indigestible must be stopped. The free or excessive use of starch and sugar must be forbidden, for instance, breads, cereals, potatoes, and foods to which much sugar is added. Nitrogenous or flesh food must be used in order to furnish the bile acid needed to hold choles-terin in solution. In this connection the observation of Thudicum is interesting, that in wild carnivora gall-stones are never observed, but that they are common in the domesticated herbivora and may occasionally be seen in pampered dogs fed on farinaceous foods. The simply prepared and easily digested vegetables, breads, and fruits may be used in moderate amounts, but the liberal consumption of starch, sugar, fats, fried foods, pastries, and other rich foods is very harmful. Even bread must be eaten moderately. The small pea, contains a choles-terin-like body, therefore, its use is generally inadvisable.

Large doses of olive oil have been recommended for the removal of gall-stones. Clinicians are much divided as to its utility. Rosenberg has shown that it acts as an efficient cholagogue, producing a copious, thin bile. Gall-stones placed in olive oil lose weight and finally break up into small particles. However, the oil as oil cannot get to the stones in the gallbladder or cystic duct. Possibly when a stone is impacted near the lower end of the common duct and all flow of bile into the intestine is stopped, the oil may find its way from the duodenum into the duct as far as the obstruction. In several instances when a calculus was thus impacted large doses of olive oil have seemed to me to do good.

Dietetic treatment is, of course, unavailing for the relief of colic. Its object is to prevent the occurrence of colic. Exercise, especially such as insures deep breathing and the use of the abdominal and body muscles, is necessary for the prevention of the formation of gall-stones. Women, who are paticularly prone to develop biliary concretions, should not lace tightly or in any way restrict their breathing.