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cholesterin formed elsewhere, especially in the cen- tral nervous system, was picked up from the blood, and excreted into the gallbladder, but there is no evidence to support this, since administration of cholesterin to animals under the skin or by mouth, does not increase the amount of cholesterin in the bile. It will be noticed that the results of catarrh in the small bile ducts anil gallbladder difl'er both in mechanism and in the nature of the calculi pro- duced. As the result of a catarrh in the small intrahepatic ducts, there is a precipitation of bili- rubin calcium, while catarrh of the gallbladder leads by a perverted metabolism of the mucous membrane to a pathological formation of chole- sterin analogous to that seen in certain cysts, such as hydroceles or ovarian cysts. The catarrh of the ducts and gallbladder may Buy Cheap Cialis Link Online be spoken of as litho- genic. If the catarrh starts in the ducts, the small calculi of bilirubinate of calcium may possibly find their way into the gallbladder and there form the nucleus of cholesterin calculi formed as the result of an extension of the inflammation to the gall- bladiler. Acute suppurative inflammation of the ducts and gallbladder does not lead to the forma- tion of calculi. This would appear to depend on the fact that destruction of the mucous cells neces- sarily ijrevents the formation Buy Cheap Cialis Link Online of cholesterin. As catarrhal inflammation is the essential antecedent of Buy Cheap Cialis Link Online cholelithiasis, it will be necessary to Buy Cheap Cialis Link Online consider what are the exciting and disposing causes of catarrhal cholecystitis and cholangitis. The exciting causes are infection with microor- ganisms and possibly the action of poison excreted into the ducts. The microbic origin of gallstones has attracted very considerable attention since it was first suggested by Galippe in 1886. Experi- mentally it has been shown that the production of cholecystitis by the bacillus of typhoid fever and the colon bacillus Buy Cheap Cialis Link Online is followed by cholelithiasis. Non- virulent cultures of streptococci and staphylococci may also give rise to calculus formation ; virulent cultures, however, set up intense cholecystitis with- out any production of calculi. From Italia's researches, it appears that pure cultures of strepto- cocci or staphylococci may lead to the formation of calculi which are composed only of lime salts : cholesterin may be found when there is an Buy Cheap Cialis Link Online admix- ture of cultures of the Bacillus coli. Thus experi- mental work, like clinical observation, shows that cholelithiasis is due to comparatively mild forms of cholecystitis, or expressed in other words, is pro- duced by an attenuated infection; this depends on preservation of the cholesterin producing epithe- lium in the slighter forms of cholecystitis and its destruction in more acute inflammations of the gall- bladder. The important microorganisms in the production of cholelithiasis are the colon bacillus and the typhoid bacillus. The most imix)rlant part in the microbic origin of biliarj' calculi is usually ascribed to bacilli belonging to the colon group. The colon bacillus has often been demonstrated inside biliary calculi ; recent calculi especially show the presence of bacilli, while old calculi usually do not, or at lK;st, show only the faintly staining shadows of microorganisms. It is genendly believed that the colon bacillus reaches the gallbladder by an ascend- ing infection of the common bile duct from the duodenum. It appears from bacteriological exami- nation of the duodenum in health that during fast- ing the mucous membrane may be sterile and that when microorganisms are found, they arc, so to s])cak, accidental and derived from the ingcsta. A factor of imix)rtance in the production of an ascending infection is more or less stagnation of the bile ; otherwise, the microorganisms would be washed out of the ducts by the bile. On the other hand, it is highly probable that the colon bacillus reaches tlic liver by the f)ortal vein and is excreted into the ducts. The causal relationship between t)'phoid fever and gallstones was suggested in 1889 by Bemhcim, of Nancy, on clinical grounds, Buy Cheap Cialis Link Online viz., the occurrence of biliary colic in patients with typhoid fever who had not previously had any signs of gallstones. Calculi have often been found in the gallbladder shortly after t\-phoid fever in patients who had not prcviouslv exhibited any signs of cholelithiasis. In tvi>hoid fever, the Bacillus t\-phosus is almost con- 936 IVEISS: GALLSTONES [New York Medical Journal. stantly found in the gallbladder after death as a rule without any calculus formation. It is, there- fore, probable that the production of calculi de- pends on the cholecystitis and Buy Cheap Cialis Link Online not on the presence of microorganisms alone. The theoretical production of cholecystitis by tox- ins without any microbic intervention is logically jKJSsible ; it has not been shown to occur in man. Disposing causes. — Many factors favor the pro- duction of catarrh of the gallbladder and bile ducts and hence dispose to gallstones. Stagnation of bile in the gallbladder does not in itself lead to the for- mation of calculi, but it renders infection more easy, since microorganisms which get into the bile are not removed, but are allowed to multiply there and may subsequently set up cholecystitis. Seden- tary habits, want of exercise, obesity, and diseases which necessitate a quiet and restful life dispose to cholelithiasis. Tight lacing frequently leads to dilatation of the gallbladder and downward dis- placement of the right lobe of the liver makes the fundus of the gallbladder more dependent than in health. A wandering liver has much the same effect. Nephroptosis, or a floating kidney on the right Buy Cheap Cialis Link Online side, may by traction obstruct the outflow of bile from the gallbladder. Among the factors that interfere with diaphragmatic respiration and, there-