Hanover were more subject to gall-stones than the neighbouring Dutchmen. But he has not brought any evidence of his proposition, so that it must be considered as unfounded.

Statements of the prevalence of gall-stones in towns and districts must, however, be always received with caution and respect, for this reason-that gall-stone disease may be epidemic amongst men, as it has been positively asserted to be now and then epidemic among horses and cattle. Both Haller and Brugmans may, therefore, have been right for their time, and cannot be judged absolutely by subsequent experience or present inquiry. Diseases which ordinarily are sporadic have been known to become epidemic. Diabetes has been epidemic (as Dr. Cockle stated from P. Frank and other writers, in his paper on that disease read before the Medical Society of London); goitre has been epidemic for a twelvemonth in a town in this country. The strangeness of an assertion of this kind challenges double vigilance on the part of the true follower of science.

Naumann (Med. Clinik,' 5, 341) has alluded to some regions of Lower Germany and Hungary as particularly favorable to the production of gall-stone disease. His assertion is much too general to deserve more than notice in this place.

As a curiosity, deserves to be noticed the announcement with which the Morning Chronicle' of London (No. 5894) once astonished its readers. It retailed the assertion of no less a man than Heberden, that in England few people attained their fortieth year without having been visited by gall-stones. If it is true, the English people must be congratulated upon such an enormous improvement in their sanitary condition as is the unavoidable conclusion from a comparison of the time of Heberden with our own.

Winter Season alleged to favour the production of Gallstone Disease.

An experience made upon cattle, that gall-stones are much more common in winter than in summer, has been transferred to man, apparently without much reason. Man is much less limited in the selection of his food than cattle, and, in the worst circumstances, not subject to the deleterious influences which cattle, particularly amongst the poorer peasantry in colder climates, have to suffer.

The circumstance alluded to in cattle is of sufficient importance to claim a special notice. The fact seems well established, as also the experience, that in spring, after green pasture, cattle part with their gall-stones. While valuable as pigments, these concretions were searched for, and not rarely found in the fæces.

Nature of Food considered as a possible cause.

All kinds of particular aliments have, at one time or another, been accused of causing these concretions, but have in turns been again completely exonerated. We know only this:-1, that flesh food predisposes least to gall-stones; 2, that vegetable food predisposes more to this disease than flesh food; 3, that mixed food affords the greatest predisposition to the disease.

Toleration, without Symptoms, of Calculi in the Gall-bladder.

We possess a great number of observations which, at first sight, tend to prove that the gall-bladder may tolerate the presence of calculi without any attempt on its part either to expel or even to react upon the intruders. Almost to

every physician who is in the habit of examining the bodies. of persons who have died under his care cases have occurred in which calculi found in the gall-bladder had not given rise to any symptoms during life referable to the seat of the concretions; the biliary passages were pervious, the interior of the gall-bladder had apparently its normal appearance, the bile had its usual colour in most instances, and although in some it appeared mixed with particles of colouring matter, interspersed with glistening crystals of cholesterine, and in others was of a more watery consistence, and in a third variety contained a large amount of mucus or loose epithelium of the gall-bladder and biliary passages, yet in the majority of instances it appeared, and probably was, of normal composition.

It must be borne in mind that when authors spoke of gall-stones which did not give rise to any symptoms they meant "symptoms denoting irritation in the biliary passages, or symptoms of painful contraction of the gall-bladder and biliary ducts, such as are the precursors and necessary accompaniments of the expulsion of these concretions." That part of the symptoms of gall-stone disease which, on account of its priority, was the most important, namely, the cacochymic aberration of the digestive process, not being understood, all symptoms occurring in that sphere remained unintelligible, and being localized in hidden regions of the body, formed no attractive subject for inquiry.

Passage of Calculi without Symptoms.

It was already known to J. P. Frank ('Epitome,' tom. ix, sect. vi, fasc. ii) that small biliary concretions do occasionally pass from persons not subject to any particular disorder, without creating any symptoms.

Symptoms of Calculi in the small and large Branches of the Hepatic Duct and the Duct itself.

Most writers on this subject-among them Wolff, supporting Budd-maintain that gall-stones produce symptoms only when lodged in the common duct. But this opinion has of late become very doubtful, as it has been found that calculi in the hepatic duct or ducts produce symptoms of a peculiar kind, differing from the symptoms of gall-stones in the gall-bladder and common duct by the absence of pain, and having the greatest resemblance to chronic intermittent fever. In one case, treated by Frerichs for a long time by means of quinine and other febrifuge remedies, the rigors and other allied symptoms simulating fever, were caused solely by calculi in the hepatic duct; their presence had not been suspected during the life of the patient.

As these calculi are rarely moved from the place in which they are formed, and as their formation is so gradual as to effect a corresponding expansion of the canal, they rarely produce symptoms of the passage of calculi, and do not easily give rise to jaundice. When a single calculus is lodged in the hepatic duct itself, it is most apt to cause partial or entire obstruction of the bile, intermittent pains of a not very severe description, and bilious vomitings. In a few cases the hepatic canal has been known to rupture, and the calculus and bile to be discharged in the abdominal cavity, where they produced an acute and fatal peritonitis.

The case of the physician, related by Fauconneau-Dufresne (p. 570), who passed concretions "which burned with a flame when held to the flame of a candle," appears to me not to admit of the assumption made by the reporter, that these calculi came from the hepatic duct.

A case of rupture of the hepatic duct, perhaps connected with, but not immediately caused by, gall-stones, has been

related by Wolff ('Raccoglitor,' March 8th, 1850; and ‘Gaz. Méd. de Paris,' 1850, p. 235). A lady, æt. 60, had for several years experienced recurrent attacks of pain in the region of the liver. On the 1st of July, 1827, she had another feeble attack, which, however, increased in severity, and caused her to vomit her dinner. She next had a violent spasm in the stomach, which compelled her to utter loud cries. On the following On the following day the pains were more violent, the abdomen was distended and painful, the extremities were cold; cold sweats, vomiting, and suppression of the pulse supervened, and notwithstanding the use of leeches, injections, opium, and blisters, the patient died twenty-four hours after the accession of the violent spasm. At the post-mortem examination the parts round the liver were carefully dissected, and the hepatic duct was found ruptured across; the two ruptured ends floated in a mass of half-coagulated blood mixed with bile. The gallbladder contained a large quantity of bile and two calculi of the size of peas; a smaller concretion was lying in the cystic duct, but did not close it entirely, and admitted of the passage of bile.

The account of this case is unsatisfactory in this respect, that it does not appear by what agency the rupture of the hepatic duct was produced; we may, however, conjecture that it was by ulceration, set up independently of gallstones, or engendered by the irritation of a gall-stone passing the hepatic duct on its journey towards the gall-bladder or common duct; the ulceration once established, the passage of gall-stones into the common duct, and the consequent obstruction of the flow of bile, can easily be understood to have effected the rupture and consequent effusion of blood and bile.