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catarrhal inflammation of the mucous membrane lining the ducts and gallbladder, leading to an al- buminous exudation which, as shown by experimen- tal addition of egg albumen to bile, precipitates bili- rubin in chemical combination with calcium as bilirubin calcium calculi (2). This is Cialis Da 20 Mg Costo the only form of calculus actually produced in the bileducts though under conditions such as impaction of a gall- stone in the common duct the formation of addi- tional calculus material containing cholesterin, as well as bilirubin calcium, takes place. Chemical an- alysis has shown that the vast majority of biliarj' calculi are composed chiefly of either or both of two Cialis Da 20 Mg Costo substances, viz., cholesterin and the calcium salts of bile pigment, known as bilirubin calcium. Either of the two substances may be the sole constituent or they may together form the mixed varieties with the two substances in almost any proportion. Cer- tain materials only occasionally enter into Cialis Da 20 Mg Costo the com- position of gallstones or do so commonly only in small amounts. These are inorganic calcium salts, notably the carbonate, sulphate, and phosphate ; small quantities of copper ; traces of iron, zinc, and manganese; globules of mercury; fats; silica; uric acid, and foreign bodies. Of the last the round worm, a portion of Distoma hepaticum, a needle, and a plum stone, have each been recorded as being the nucleus of a calculus. The presence of calcium salts in mixed calculi, particularly the carbonate, contributes hardness ; in rare instances, the concre- tions ma}' be chiefly or entirely calcareous. The bile acids and other constituents of bile are found in calculi only in such small traces as are explained by the absorption of this Cialis Da 20 Mg Costo fluid in the interstices. Again, the bile pigment in combination with calcium is not always bilirubin, but frequently in part biliverdin or bilifuscin. It may be said that in general cholesterin predomi- nates in the larger stones, while tlie smaller are more apt to contain considerable bilirubin calcium, Naunyn, in his admirable treatise on cholelithiasis, recognizes six classes of gallstones : i. Pure choles- terin : Usually pure Cialis Da 20 Mg Costo white or yellowish, translu- cent : in rare instances dark colored ; ordinarily, oval or roughly spherical in form, hard, seldom exhibit facets, not stratified or only feebly so, and var)' in size from a cherry to a pigeon egg. 2. Laminated cholesterin : Contains ninety per cent, or more of cholesterin, the other constituents being calcium compounds of the bile colors and calcium carbonate, are usually hard, but occasionally when dry, brittle and friable ; more frequently facetted than the first variety; more or less distinctly laminated with th': layers, perhaps, differing in color; often with those nearer the centre more crystalline in structure and those nearer the surface hardened by the presence of calcium carbonate. They resemble cholesterin stones in form and size, but are not apt to be some- what darker in color. 3. Common gallstones : These comprise the great bulk of gallstones, varying in size, composition, and form and tint ; usually facet- ted and laminated ; the soft nucleus may consist of bilirubin calcium or of a cavity holding a yellowish alkaline liquid. If soft when removed, they harden and shrink in drying without developing fissures. 4. Mixed bilirubin calcium : Usually the size of a cherry, occur in groups of three or four, and are facetted. They are twenty-five per cent, or less cholesterin, the remainder being chiefly bilirubin calcium. Cialis Da 20 Mg Costo They have a brown color, are seldom hard, and develop fissures when they dry. 5. Pure bili- rubin calcium : Common in cattle, rare in man. In calculi of this class, bilifuscin is practically always present. 6. Rarer forms : Amorphous and incom- pletely crystalline cholesterin gravel ; small ; often resembling pearls, and always with a nucleus of different structure. Calcareous forms consisting almost entirely of calcium carbonate. Concretions which include foreign, bodies and conglomerate May i8, 1918.] WEISS: GALLSTONES. 935 stones. Casts of bileducts. Schade divides them into three types, pure cholesterin, biHrubin calcium, and pigniLiit calcium ciiolcslcrin. The stones are usually found within the gallblad- der, less frequently in the cystic or common duct and in the alimentary tract, having passed down from the gallbladder. The diagnosis of intrahepatic calculi is not made during life; such calculi occur in 8.3 per cent, of the gallstone cases that come to autopsy. Noguchi reports a case where the stone was not found in the bladder or duct but was felt in tiie liver Cialis Da 20 Mg Costo at operation and successfully removed. A single calculus may be present in the gallbladder ; it is usually ovoid and may be quite large. The number of stones may be very great, 7,802 having been reported in one case. The average size is apt to vary inversely with the number, from Cialis Da 20 Mg Costo that of a pinhead to a cherry, as in my own cases here illus- trated. When numerous, they may be the size of small grains, while, on tiic other Cialis Da 20 Mg Costo hand, Meckel has described a single biliary calculus fifteen centimetres long and si.K broad. When more than a few are present, they conimordy lose their ovoid shape and show signs of mutual pressure, having a polygonal form with smooth facets. All those present in one individual commonly have the same chemical com- position and present the same physical characters, but may vary considerably in size. Simple stagnation and inspissalion of bile do not lead to the precipitation of liilirul)in calcium calculi. Something more than inspissalion, c.