,frontispiece3 ,plate ,i4 ,occlusion of the ,bile1 and ,pancreatic ,ducts4 ,,jaundice3 ,,its ,,pathology ,,and ,,treatment4 ,,with ,,the ,,application ,,of ,,physiological ,,chemistry ,,to ,,the ,,detection ,,and ,,treatment ,,of ,,diseases ,,of ,,the ,,liver ,,and ,,pancreas4 ,,by ,,george ,,harley1 ,m4,d41 ,professor of ,medical ,jurisprudence in ,university ,college1 ,london2 ,assistant ,physician to ,university ,college ,hospital2 ,formerly ,president of the ,parisian ,medical ,society2 ,cor4 ,memb4 of the ,academy of ,sciences of ,bavaria1 and of the ,royal ,academy of ,medicine of ,madrid4 ,so rapid is the advance of science1 that the theory regarded as true to-day1 may be recognised as false to-morrow4 ,the facts1 however1 on which the theory is based1 if rightly observed1 remain unaltered1 and unalterable4 ,,london3 ,,walton ,,and ,,maberly1 ,,upper ,,gower ,,street1 ,,and ,,ivy ,,lane1 ,,paternoster ,,row4 ,,mdccclxiii4 ,,london3 ,,william ,,stevens1 ,,printer1 #cg1 ,,bell ,,yard1 ,,temple ,,bar4 ,,to ,,william ,,sharpey1 ,m4,d41 ,,ll4,d41 ,f4,r4,s41 ,professor of ,anatomy and ,physiology in ,university ,college1 ,london1 ,,as ,a ,,small ,,token ,,of ,a ,,colleague',s ,,esteem ,,for ,a ,,profound ,,thinker1 ,a ,,sound ,,reasoner1 ,,and ,a ,,true ,,friend4 ,,preface4 ,time being money1 quite as much to the professional as it is to the mercantile man1 the author has endeavoured in the accompanying monograph not only to condense his material1 but to exclude the consideration of any question not directly bearing upon the pathology or treatment of jaundice2 indeed1 as stated in the ,introduction1 one of the chief objects of the author having been to point out how valuable an adjunct modern physiological1 and chemical knowledge is in the diagnosis1 and treatment of hepatic and pancreatic disease1 he has neither dwelt on the literature nor discussed the old theories of the mechanism of jaundice1 but limited himself almost entirely to a brief exposition of his own views4 ,for the sake of brevity1 he has at page #acb put into a tabular form the pathology of jaundice1 according to the opinions expressed in the body of the volume4 ,as the object of all theory1 and the aim of all science1 is to insure wise practice1 the author desires to call special attention to that portion of the work devoted to the chemistry of the excretions1 feeling1 as he does1 that we are entering upon the threshold of an important department of medical inquiry1 which1 sooner or later1 will be followed by valuable practical results4 ,he would also direct the special attention of his readers to the chapter devoted to treatment1 being sanguine enough to imagine that the adoption of the principles he has enunciated regarding the mode of action1 and administration of the remedies usually employed in hepatic affections1 may conduce to a more rational and successful method of treatment than has hitherto been employed4 ,he even goes far enough to hope that the result of the treatment1 as shown in the cases cited1 will not only justify the adoption of the principles on which it is founded1 but also prove a strong incentive to others to follow the line of diagnosis he has striven to inculcate4 ,in some portions of the volume the statements of the author may1 perhaps1 appear to be rather dogmatic2 if so1 he would remind his readers that this has arisen from the circumstance of so many old dogmas1 and deeply-rooted prejudices having to be combated1 for he is quite alive to the fact1 that what we regard as scientific truth is in no case incontrovertible certitude1 and that the deductions of to-day1 in an advancing science like that of medicine1 may require material alteration when viewed in the light of the morrow4 ,but he is equally convinced of the fact1 that if men fold their arms1 and refrain from acting until every link in the chain of knowledge is forged1 all progress will be arrested1 and the day of certainty still further postponed4 ,too long have we reversed the natural order of things1 and commenced the study of medicine where we ought rather to have left it off4 ,too long have we striven1 by studying pathology ere we were sufficiently acquainted with physiology1 to place the pyramid on its apex instead of on its base2 and thus it is we remained so long ignorant of the fundamental doctrine1 that the same laws which regulate health1 regulate disease4 ,nature does nothing on a small scale1 and the more we study her the more we admire the uniformity1 and extensive applicability of her laws4 ,if we pry into the ultimate structure of our bones1 we find they receive their nutriment by a system of irrigation1 carried on through lakes1 and rivers 7lacun1 and canaliculi72 and if we examine the periosteum surrounding them1 the ligaments attaching them1 or the muscles covering them1 we still find1 that1 notwithstanding the diversity in structure1 and use1 the one system of irrigation pervades them all4 ,we may even go a step further1 and say that the same law which governs the animal governs also the vegetable kingdom4 ,indeed1 the further science advances1 the more apparent does it become1 that not only the animal1 and vegetable1 but even the organic1 and inorganic1 form but one world1 regulated by the same laws4 ,a knowledge of organization1 important though it be1 is yet less indispensable to the physician than a knowledge of healthy function1 for it is the latter which elucidates the dark problems of life1 it is the latter which proves the golden key to the comprehension of disease4 ,although not even the most ardent admirers of medicine can say1 that it as yet merits the name of an exact science1 this ought neither to destroy our hopes nor trammel our labours4 ,with the stethescope1 microscope1 and other physical means of diagnosis a new era dawned upon our art2 and now the members of the new school which is rising up1 and carrying chemistry into the domains of medicine1 are the pioneers of the revolution which is soon to follow4 ,if we look back to what the exact sciences of to-day were in former times1 we shall find they were much less perfect then1 than medicine is now4 ,astronomy and chemistry were but astrology and alchemy4 ,if1 then1 we draw a picture of the future from the progress of the past1 we need have no hesitation in saying that chemistry rightly applied1 and physiology justly interpreted will1 ere many generations pass away1 reveal the deepest secrets of diseased action1 and although unable to banish death1 will yet enable the practitioner to follow with unerring certainty the various morbid changes occurring in the frame4 #gg1 ,,harley ,,street1 ,,cavendish ,,square1 ,march1 #ahfc4 ,,contents4 ,,page ,,introduction 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 #a ,pathological conditions with which jaundice is associated--,those of the liver itself--,those of the bile-ducts--,general affections of other organs of the body exerting an influence on the biliary secretion--,zymotic diseases--,the effects of certain poisons 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 #c ,frerichs's theory of jaundice--,theory of jaundice hitherto most favoured in ,england--,dr4 ,budd as its exponent 4 4 4 4 4 4 4 4 #f ,nature of bile--,biliverdine--,bile acids2 glycocholic1 and taurocholic acids--,cholesterine--,bile resin--,sugar--,inorganic constituents--,specific gravity1 reaction1 and colour of normal bile 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 #g ,manner in which bile is secreted--,liver both a formative and excretive organ--,animals without gall-bladders--,effects of food on the colour and quantity of the bile 4 4 4 4 4 4 4 4 4 #aa ,is bile essential to life8--,effect on the system of absence of bile in the digestive process--,death from starvation as a result--,benefit derived from an additional quantity of food--,uses of bile in the animal economy--,necessary to the absorption and assimilation of food--,bile as a digestive agent--,its action on the chyme--,experiments on its influence over the absorption of fatty matter--,its relation to the pancreatic juice--,bile taken internally by ,caffres 4 4 4 4 4 4 #ac ,general view of the mechanism of jaundice--,two great divisions--,jaundice from suppression1 and jaundice from re-absorption--#ast subdivision3 jaundice arising from enervation1 disordered hepatic circulation1 and absence of secreting substance--#bnd subdivision3 jaundice arising from congenital deficiency of the bile-ducts1 and from accidental obstruction of the bile-ducts 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 #ai ,general view of the pathology of jaundice from suppression1 showing how the coloration of the skin1 and urine is produced in such cases 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 #bj ,mechanism of jaundice as a result of enervation--,influence of nervous system on secretion--,effect of mental emotion on biliary secretion1 as observed in dog with biliary fistula--,action of fright in paralyzing nerve force 4 4 4 4 4 #bb ,mechanism of jaundice from hepatic congestion--,active congestion--,general view of the effects of congestion on glandular secretion--,reason why the biliary secretion is not usually completely arrested--,the absence of pipe-clay stools explained--,example of jaundice from hepatic congestion--,jaundice from zymotic disease1 and other cases of blood-poisoning1 have a similar mechanism--,example of jaundice following upon ague--,effect on the urine--,analysis of the urine a clue to the nature of the case 4 4 4 4 4 4 4 4 4 4 4 4 #bd ,passive congestion of the liver as a cause of jaundice--,cases associated with heart disease1 pneumonia1 c4--,explanation of the reason why jaundice is so frequently absent in such cases #bi ,mechanism of jaundice arising from suppression consequent upon absence of the secreting substance--,cancer1 tubercle1 c4--,effects of the position of the morbid deposit in modifying the result 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 #ca ,jaundice arising from acute1 or yellow atrophy of the liver--,state of the urine in such cases--,presence of bile-acids--,pettenkofer's test--,tyrosine and leucine in the urine--,an example of the affection occurring in a young woman--,exciting cause--,state of the liver tissue--,poisonous effects of glycocholate of soda injected into the circulation #cd ,mechanism of jaundice arising from the re-absorption of the secreted but retained bile--,jaundice arising from a congenital deficiency of the ducts--,history of a case 4 4 4 4 #ci ,pathology of jaundice resulting from the accidental obstruction of the bile-ducts--,mode of formation of gall-stones--,jaundice only present when the stone is lodged in common duct--,how gall-stones may imperil life without inducing jaundice--,modes of escape from the gall-bladder--,presence of foreign bodies1 such as cherry-stones in gall-duct--,jaundice arising from hydatids impacted in the common duct 4 4 4 4 4 4 4 4 4 4 4 4 4 #db ,mechanism of permanent jaundice from obstruction--,resulting from organic disease--,cancer of head of pancreas--,effect of the dilatation of the bile-ducts in the liver--,effect on the nutrition of the parenchyma of liver--,different stages in size through which the liver passes--,difficulties of diagnosis--,cause often obscure--,key to its detection 4 4 4 4 4 #df ,analysis of the intestinal secretion an aid to the diagnosis of obscure cases of abdominal disease--,colour1 nature1 and chemical composition of the stools--,changes produced in them by different foods1 and remedies 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 #ea ,examination of the renal secretion--,diagnostic value of the colour of the urine--,colour produced by urohmatin to be distinguished from that produced by biliverdine--,simple method of separating the pigment from the urine--,advantage of at the same time ascertaining the quantity of uric acid present--,effect of the bile pigment becoming deposited in the kidneys--,production of secondary disease 4 4 4 4 4 4 4 4 4 4 4 #ee ,diagnostic value of the presence of the bile-acids in the urine--,views of ,frerichs1 ,stdler1 and ,khne--,hoppe's method of detecting the bile-acids--,frerichs's theory of the transformation of bile-acids into biliverdine shown to be untenable 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 #eh ,diagnostic value of the presence of tyrosine1 and leucine in the urine--,microscopic appearances of these substances--,mode of separating them from urine--,chemical tests 4 4 4 4 4 4 4 4 4 4 #fc ,melanine in the urine in cases of cancer of the liver--,the characters by which it is to be distinguished from bile pigment--,case related showing the value of the test 4 4 4 4 4 #fh ,diagnostic value of ascertaining the quantity of urea1 and uric acid1 as well as the presence of sugar in the urine in obscure cases of jaundice--,history of a case illustrating the value of such knowledge--,significance of the presence of fatty acids in the fces in the diagnosis of pancreatic disease--,pancreatine administered--,effect of bile-poisoning on the memory--,analysis of the patient's urine--,diagnostic value of the quantity of its constituents pointed out--,appearance of sugar as the forerunner of a fatal termination alluded to--,disappearance of bile-acids1 and appearance of tyrosine and leucine in the latter stages of the disease--,post-mortem appearances described--,occlusion of bile1 and pancreatic ducts--,analysis of healthy and diseased bile--,change in the proportion of the organic greater than in that of the inorganic constituents--,microscopic appearances of liver--,presence of crystals of cystine1 as well as of tyrosine in the hepatic parenchyma 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 #gj ,jaundice from obstruction in its latter stage complicated with jaundice from suppression 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 #hi ,epidemic jaundice--,among soldiers--,among pregnant women--,among the entire civil population--,its mechanism--,its cause--,case of jaundice supervening upon scarlatina 4 4 4 4 4 4 4 4 4 4 4 4 4 #ij ,artificial jaundice--,mode of production--,experiments related--,tyrosine1 and leucine supposed to be the result either of the arrested1 or of the retrograde metamorphosis of glycocholic1 and taurocholic acids--,biliary acids detected in the blood--,poisonous nature of the constituents of the bile--,condition of the blood in bile-poisoning 4 4 4 4 4 4 4 4 #ie ,treatment of jaundice--,totally different in jaundice from suppression and in jaundice from obstruction--,benefit of mercury in cases of jaundice--,general theory regarding the action of mercurials--,benefit of acids1 and of alkalies--,their mode of action explained--,theory of their action in cases of gall-stones--,lithia water--,treatment of jaundice by benzoic acid--,cases illustrating its mode of action--,podophyllin a bane1 and an antidote in cases of jaundice--,its pernicious effects in cases of obstruction pointed out--,author's theory of its action in such cases--,method of detecting gall-stones in the stools--,sulphuric ether1 and chloroform in cases of gall-stones--,taraxacum 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 #aja ,difficulties in the treatment of jaundice from obstruction pointed out--,derangements arising from absence of bile in the digestive process--,good effects of an additional quantity of food--,establishment of an artificial biliary fistula shown to be less hazardous than usually imagined--,mode of operation explained--,treatment of permanent jaundice by prepared bile--,new mode of preparing bile pointed out--,theory of its action--,time of administration shown to be of much importance--,bile put into capsules--,benefits derived from bile given in this form 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 #abb ,tabular view of the pathology of jaundice according to the author's views 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 #acb ,,index 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 #acc ,,description ,,of ,,plates ,,and ,,woodcuts4 ,,plate ,i4 ,represents the condition of the parts in a fatal case of permanent jaundice1 in which both the bile1 and pancreatic ducts were completely occluded4 7a7 ,atrophied liver4 7b7 ,transverse section of the left lobe1 showing the mouths of the enormously distended gall-ducts4 7c7 ,enlarged gall-bladder4 7d7 ,dilated cystic duct4 7e7 ,distended hepatic1 and common duct4 7f7 ,ulceration in duodenum1 in the situation of the opening of the gall-duct into the intestines4 7g7 ,pancreas with enlarged head 7h71 and enormously distended duct4 ,,plate ,,ii4 ,external surface of the left kidney1 denuded of its capsule1 in a case of permanent jaundice4 7a7 ,small specks of bile pigment deposited in the renal tissue1 and blocking up the urine tubes4 7b7 ,small abscesses scattered throughout the tissue of the kidney4 ,,woodcuts4 ,fig4 #a4 ,crystals of glycocholate of soda1 mag4 #ij diam4--,page #h4 #b4 ,taurocholate of soda1 as found in the form of globules of various sizes4--,page #i4 #c4 ,crystals of cholesterine4--,page #i4 #d4 ,crystals of pure tyrosine4--,page #fc4 #e4 ,spiculated balls of tyrosine1 from the urine of a case of acute atrophy of the liver4--,page #fd4 #f4 ,globules of leucine4--,page #ff4 #g4 ,cholesterine crystals4--,page #hb4 #h4 7a7 ,crystals of cystine4 7b7 ,hepatic cells1 showing entire absence of fat globules4 7c7 ,caudate or spindle-shaped cells1 from epithelial lining of hepatic ducts4--,page #hf4 #a ,,jaundice3 ,,its ,,pathology ,,and ,,treatment4 ,,introduction4 ,having entitled this monograph ,jaundice1 its ,pathology and ,treatment1 it may1 perhaps1 be necessary for me to state at the beginning that by so doing it is not to be supposed that ,i regard jaundice as a disease per se4 ,on the contrary1 ,i look upon it in the same light as ,i do albuminuria1 which is not of itself a disease1 but only the most prominent symptom of several widely-differing pathological conditions4 ,so also the peculiar state of body characterised by yellow skin1 saffron-coloured urine1 and pipe-clay stools1 is itself but a symptom of morbid action4 ,it may be asked1 ,then why do you treat of jaundice as if it were a disease8 ,to this ,i reply1 ,because1 although #b the condition called jaundice be merely a manifestation of morbid action1 and one1 too1 requiring neither skill nor experience to detect1 the proper comprehension of its true mechanism is of much practical importance to the physician1 for without this knowledge it is impossible for him to treat it with any chance of success4 ,nay1 even the remedies for jaundice become dangerous weapons1 if unskilfully applied4 ,in fact1 it is almost unnecessary to apologise for treating of jaundice as a disease per se2 for1 notwithstanding all that has been written upon the subject1 it is universally admitted that the simplicity of its diagnosis is only equalled by the obscurity of its pathology1 and the uncertainty of its treatment2 and no one at all conversant with the literature of jaundice can be in the least degree surprised at this statement4 ,on the contrary1 on glancing at the immense variety of morbid states1 and known pathological conditions with which it is associated1 he cannot fail to admit its truth4 ,some of the pathological conditions are closely allied2 others are widely separated--so widely1 indeed1 that at first sight it is impossible to discover from whence emanates the common symptom4 ,we find jaundice connected with diseases of the liver1 of the neighbouring organs1 and of the general system4 ,in some diseased conditions1 #c jaundice presents itself when least expected4 ,at other times it is absent when1 apparently1 it ought to be present4 ,on the other hand1 again1 there are cases in which jaundice is evidently merely a symptom1 and others in which it seems to be in itself the disease4 ,we have temporary jaundice from transient derangements1 and we have permanent jaundice from stationary causes4 ,there are cases in which the cause of jaundice is visible after death to the naked eye4 ,there are others where the minutest research is baffled in ascertaining the cause4 ,that this is no exaggerated view of the case the following table will show3-- ,,jaundice ,,is ,,met ,,with1 ,firstly1 ,,in ,,diseases ,,affecting ,,the ,,liver-- 7a7 ,cancer4 7b7 ,tubercle4 7c7 ,cirrhosis4 7d7 ,inflammation4 7e7 ,atrophy4 7f7 ,amyloid1 and 7g7 ,fatty degeneration4 ,secondly1 ,,in ,,diseases ,,of ,,the ,,bile-,,ducts-- 7a7 ,congenital deficiency4 7b7 ,accidental obstruction4 ,the latter arising from gall-stones1 hydatids1 foreign bodies #d 7such as cherry-stones and entozoa7 entering from the intestines4 7c7 ,ulcer of the duodenum4 7d7 ,tumours of the pancreas4 ,thirdly1 ,,in ,,affections ,,of ,,other ,,organs ,,of ,,the ,,body ,,exerting ,,an ,,influence ,,on ,,the ,,biliary ,,secretion-- 7a7 ,diseases of the nervous system4 7b7 ,diseases of the lungs4 7c7 ,diseases of the heart4 7d7 ,imperfect establishment of the extra-uterine circulation 7infantile jaundice74 7e7 ,dyspepsia4 7f7 ,torpidity of the bowels1 and consequent accumulation of fces in transverse colon4 7g7 ,pregnancy4 ,fourthly1 ,,in ,a ,,variety ,,of ,,zymotic ,,diseases-- 7a7 ,typhus4 7b7 ,yellow fever4 7c7 ,ague4 7d7 ,pymia4 7e7 ,epidemic jaundice4 ,fifthly1 ,,as ,a ,,result ,,of ,,the ,,injurious ,,effects ,,of ,,certain ,,poisons-- 7a7 ,snake bites4 #e 7b7 ,alcohol4 7c7 ,chloroform1 etc4 ,can it be wondered1 then1 that a state so easily diagnosed is nevertheless so difficult to comprehend8 ,notwithstanding the apparent incongruity of the diseases with which the one common symptom of jaundice is associated1 ,i trust to be able to reconcile these discrepancies1 and prove that the seeming discord is but harmony not understood4 ,all physicians1 ,i think1 admit that the peculiar state of the system to which the name of jaundice has been applied1 is essentially due to some derangement of the biliary function1 the exact nature of the derangement being alone the point of contention4 ,i need not1 therefore1 waste the time of my readers1 either by giving an account of the literature or a detail of the symptoms of jaundice4 ,even in discussing its pathology1 ,i shall strictly limit myself to the consideration of the opinions at present held by the more advanced of our pathologists2 the object of this monograph being1 not to pourtray the views of others1 but to give a brief expos of my own1 and to point out how modern physiology1 and chemistry have not only thrown a new light on its pathology1 but have also given us a clue to its successful treatment4 #f ,frerichs1 the most recent writer on this subject1 in his elaborate treatise on diseases of the liver1 says that jaundice may result from one of the three following conditions3-- ,firstly1--,obstruction to the escape of bile4 ,secondly1--,diminished circulation of blood in the liver1 and consequent abnormal diffusion2 both of these conditions giving rise to an increased imbibition of bile into the blood1 and in both cases the liver being more or less directly implicated4 ,thirdly1--,obstructed metamorphosis1 or a diminished consumption of bile in the blood4#a ,footnote #a3 ,frerichs' ,clinical ,treatises on ,diseases of the ,liver4 ,new ,sydenham ,society's ,translation1 vol4 i4 p4 #ic4 ,from this it is seen1 that the pathology of jaundice1 according to ,frerichs1 is very different from what we were formerly taught4 ,for while he has entirely laid aside the theory of jaundice as a result of suppressed secretion1 he has introduced two perfectly new elements--namely1 abnormal diffusion1 and diminished consumption4 ,the latter theory1 being1 of course1 founded on the supposition that bile1 after playing its part in the digestive process1 is re-absorbed into the circulation1 again to perform another function in the animal economy1 before its final excretion from the organism as effete matter4 ,the theory of jaundice1 hitherto most favoured in ,england1 and which found #g such an able exponent in ,dr4 ,budd1 is1 that the disease may arise in two ways--firstly1 by a mechanical obstruction to the passage of bile into the intestines1 and the consequent re-absorption of the detained fluid into the blood2 and secondly1 by a suppression of the biliary secretion arising from some morbid condition of the liver itself1 whereby the biliary ingredients accumulate in the circulation4 ,now1 although ,i am not prepared to admit the justice of the views held regarding the origin and function of bile1 on which these opinions are based1 ,i nevertheless believe that in the following pages ,i shall be able1 by the aid of modern medical science1 to prove the correctness of the conclusions themselves4 ,in order to do this1 however1 it will be necessary for me to begin by making a few remarks on the nature of bile1 and the physiology of its secretion4 ,,on ,,the ,,nature ,,of ,,bile4 ,in a few words1 bile may be said to be composed of the following substances3-- ,firstly1--,biliverdine1 a green nitrogenized1 non-crystallizable colouring matter1 analogous to the green colouring matter of plants1 and like it1 leaving on incineration a distinctly ferruginous ash4 ,this colouring matter appears1 like #h urohmatine1 and all other animal pigments1 to be a direct derivative of the colouring matter of the blood4#b ,footnote #b3 ,vide papers by the author on the colouring matter of the urine1 ,pharm4 ,journ41 ,november1 #aheb4 ,urohmatine1 and its combination with animal resin4 ,verh4 d4 ,phys4-,med4 ,gesellschaft zu ,wurzburg1 ,bd4 ,v4 #ahed4 ,illustration3 ,,fig4 #a4 ,crystals of ,glycocholate of soda1 a beautiful polariscopic object4 7a7 ,fine needle-shaped crystals1 separated from a rosette-shaped group4 7b7 ,small rosette of crystals4 7c7 ,fan-shaped groups of crystals1 which are merely portions of large rosettes that have become broken up4 7d7 ,a fragment of a bundle of needle-shaped crystals4 ,mag4 #ij diam4 ,secondly1--,two peculiar substances1 named respectively1 glycocholic1 and taurocholic acid--the former yielding1 when in combination with soda1 a crystallizable1 the latter a non-crystallizable salt4 ,taurocholic differs still further from glycocholic acid1 in containing a large percentage of sulphur1 #i and being1 under the influence of hydrochloric acid1 convertible into taurine1 a beautiful white crystalline substance4 ,illustration3 ,,fig4 #b4 ,taurocholate of soda is found in the form of fatty-looking globules of various sizes4 ,they differ from fat and oil globules1 however1 in being soluble in water1 and insoluble in alcohol and ether4 ,thirdly1--,cholesterine1 a crystalline1 fatty matter1 not1 however1 peculiar to bile1 but found in various tissues1 and secretions of the body4 ,illustration3 ,,fig4 #c4 ,cholesterine crystals appear in the form of fine transparent four-sided plates of various sizes and shapes4 ,the crystals are freely soluble in hot alcohol1 from which they are re-deposited on cooling4 #aj ,fourthly1--,a brown resinous substance resembling1 in appearance and consistence1 shoemaker's wax4 ,fifthly1--,among the constituents of the bile1 ,i may mention sugar1 for both in the normal bile of man1 and of the lower animals1 the ox1 and the dog1 ,i have detected that substance4 ,on one occasion1 ,i even found torul in the bile twenty-four hours after its removal from the gall-bladder of a healthy dog4 ,sixthly1 and lastly1--a quantity of inorganic matter1 consisting chiefly of soda1 potash1 and iron4 ,the specific gravity of bile fluctuates1 of course1 with the percentage of solid matter it contains4 ,from my own observations1 ,i consider that healthy human bile has an average specific gravity of #ajbj1 and contains about six per cent4 of solid matter1 five per cent4 of which is organic1 and one per cent4 inorganic substance4 ,when fresh1 bile is almost neutral2 but it rapidly undergoes decomposition1 and becomes alkaline4 ,in colour1 human bile is usually of a brownish yellow hue2 the colour1 however1 varies with its degree of concentration1 the kind of food taken1 and the state of the system4 ,as regards the effect of food1 if we may be allowed to form an opinion from experiments on dogs1 it may be said that1 as a #aa rule1 animal food tends to give bile a yellow1 vegetable food a green1 tint4 ,next1 as regards the manner in which bile is secreted4 ,for a long time it was thought1 and1 indeed1 some people still think1 that bile exists pre-formed in the blood1 and that the liver only excretes it1 as the kidneys excrete the urinary ingredients4 ,another class1 running to the opposite extreme1 believe that the liver is not merely the excretive1 but also the formative organ of the bile4 ,it appears to me1 however1 that neither of these extreme views is correct1 and that the truth lies between the two4 ,it is1 in fact1 not at all difficult to prove that the liver manufactures certain biliary constituents1 while it merely excretes others4 ,thus1 for example1 the two substances glycocholic and taurocholic acids are never to be found either in the blood1 tissues1 or fluids of the healthy organism1 with the single exception of those of the liver and gall-bladder2 and after extirpation of the liver neither acid is to be found in the body at all4 ,on the other hand1 such substances as cholesterine and biliverdine1 are not peculiar to the liver or its secretion1 but are the products of several organs1 and are always to be detected in the blood1 independently of the presence or absence of the liver4 ,these facts1 therefore1 clearly show that the liver #ab is both a formative and excretive organ to some1 and an excretive only to others1 of the biliary constituents4 ,lastly1 the general opinion is that the secretion intermits1 and1 like the gastric1 and pancreatic juices1 bile is only formed during digestion4 ,were it so1 however1 where would be the necessity for a gall-bladder8 ,is it not to store up the secretion formed in the intervals of digestion1 and to retain it until it is required8 ,no doubt there are several animals1 such as the horse1 and the deer1 that possess no gall-bladders2 but there is undoubtedly in them some special arrangement of the digestive apparatus1 rendering the presence of a gall-bladder unnecessary4 ,in fact1 it is easily shown that the biliary secretion in ordinary cases is continuous2 for if in an animal possessing a gall-bladder a biliary fistula be established1 and the secretion of bile carefully watched1 it will be found that at no period of the day does it entirely intermit1 although it is more active at one time than at another1 the minimum of its activity being during sleep--the maximum during active digestion4 ,the absolute quantity of bile secreted in the twenty-four hours is tolerably uniform1 although the daily amount is slightly influenced by the kind of food4#c ,footnote #c3 ,arnold found that dogs secreted more bile on a bread1 than on an animal diet4 ,zur ,physiologie der ,galle1 ,mannheim1 #ahed4 #ac ,,is ,,bile ,,essential ,,to ,,life8 ,several physiologists have given it as their opinion that bile is not essential to life1 for animals have lived for many months after the artificial establishment of a biliary fistula1 through which the bile was allowed to flow away1 and be lost to the animal4 ,now1 although this is perfectly true1 yet it is at the same time evident that the uses of the bile cannot altogether be dispensed with1 for all the animals with a biliary fistula lose flesh1 become emaciated1 and weak2 the hair has a tendency to fall off1 the bowels to become irregular2 and a great and an almost constant discharge of foul-smelling gases takes place from the intestinal canal4 ,at length1 after a shorter or longer period1 the animal sinks1 and dies4 ,the fatal termination can1 however1 be retarded by allowing him an additional quantity of nourishing food1 for death from want of bile1 as is too often seen in the human subject1 is nothing else than death from slow starvation4 ,the fact just related regarding the beneficial effects of an additional quantity of food in prolonging life1 should never be lost sight of in the treatment of cases of obstruction of the gall-ducts1 for1 by attending to this circumstance1 it is often in the power of the medical man to keep his patient alive for a considerable length of time4 #ad ,it may perhaps not be out of place if ,i here briefly enumerate the chief uses of bile in the animal economy4 ,in order to live1 not only must the individual particles of our frames die1 but they must be continually replaced by new materials of a similar kind2 and for the accomplishment of this important end1 nature has endowed animals with a digestive apparatus in which their food undergoes the various physical1 and chemical changes necessary to its absorption1 and assimilation4 ,in the animal laboratory or digestive apparatus there are five important agents constantly at work--saliva1 gastric juice1 bile1 pancreatic fluid1 and intestinal secretion1 and each of these agents has a special and definite office to perform in the elaboration of the food4#d ,at present1 however1 ,i must limit myself entirely to the consideration of bile4 ,footnote #d3 ,for an explanation of these offices1 see the author's article on ,the ,chemistry of ,digestion1 in the ,british and ,foreign ,quarterly ,review1 ,january1 #ahfj4 ,bile is the first digestive agent with which the food comes in contact on leaving the stomach and entering the intestines1 and immediately on the acid chyme mixing with the alkaline bile1 a white flocculent emulsion is formed1 which emulsion has been described by many writers as a precipitation of the albuminose 7digested albumen74 ,later #ae researches by myself and others have1 however1 shown that it is not the bile which precipitates the albuminose1 but the acid of the chyme1 which in reality sets free certain ingredients of the alkaline bile4 ,in the majority of cases there is not even a true precipitation1 for on throwing the milky-looking mixture upon a filter1 ,i found that almost nothing remained behind1 and the filtrate was nearly as white as the original liquid4 ,further1 if the albuminose be separated from the chyme1 and the chyme then brought into contact with the bile1 the same flocculent-looking milkiness still appears4 ,nay1 more1 on adding equal parts of sheep's bile 7fresh7 to gastric juice drawn from a dog's stomach in full digestion1 the apparent flocculent precipitate still appeared1 although the acidity of the gastric juice remained unneutralized2 and on throwing the whole into a filter1 ,i found that the liquid that drained through was as milky and flocculent-looking as the original4 ,the office of bile in the digestive process is neither to act on the albuminous#e nor amylaceous portions #af of our food2 its chief action being to assist in the absorption of fats4 ,when bile is mixed with neutral fat1 little change is observed1 but when brought in contact with the fatty acids1 an immediate emulsion takes place4 ,lenz and ,marcet#f pointed out how the neutral fats of our food are transformed into fatty acids during their sojourn in the stomach2 and ,bidder and ,schmidt#g illustrated by experiments on dogs the important part played by the bile in their absorption4 ,a dog1 which in its normal condition absorbed on an average #g grains of fat for every #b pounds of its weight1 absorbed only #c1 or even as little as #a grain1 after the bile was prevented entering the intestines1 in consequence of a ligature being applied to the gall-duct4 ,footnote #e3 ,in speaking of the properties of the bile1 ,i may mention that1 although bile has no digestive power 7properly speaking7 over albuminous substances1 yet1 when injected into the subcutaneous cellular tissue of a healthy animal1 it eats its way out through the skin1 just as gastric juice or lactic acid does under similar circumstances4 ,even the muscles with which it comes in contact appear to be eaten away4 ,footnote #f3 ,vide a ,discourse on the ,chemistry of ,digestion1 by ,dr4 ,marcet4 ,journ4 of the ,chem4 ,soc41 ,oct4 #ahfb4 ,footnote #g3 ,die ,verdauungssaefte und der ,stoffwechsel4 ,leipzig1 #aheb4 ,further1 these last-named observers found that1 while the chyle in the thoracic duct of a healthy dog contains #cb parts of fat per thousand1 that in the thoracic duct of a dog with a ligatured gall-duct1 contains only #b parts per thousand4 ,these facts clearly prove that bile plays an important part in the absorption of the fatty portion of our food4 ,next comes the question1 ,in what manner does bile aid in the absorption of fatty matter8 #ag ,as is well known1 fats or oils have no tendency to mix with water1 and hence diosmose between an aqueous and an oily fluid is next to impossible4 ,matteucci has1 however1 shown that if an animal membrane be moistened on both sides with a weak solution of potash1 it allows oil to pass through it4 ,it has also been observed1 that when the intestine is moistened with bile1 it allows oil to pass through1 which would not otherwise be the case4 ,to illustrate this property of bile1 ,i performed the following experiments3-- ,firstly1--,a clean piece of duodenum was filled with oil1 ligatured at both ends1 and suspended in water1 holding in solution a small quantity of albumen4 7,the albumen was added to the water merely to imitate slightly the albuminous blood47 ,on examination1 twenty-four hours later1 no oil was found to have escaped through the intestinal walls4 ,secondly1--,a second portion of intestine had its internal surface moistened with sheep's bile before the introduction of the oil4 ,it was then treated in the same manner as the preceding1 and on being examined after the lapse of twenty-four hours1 a small quantity of the oil was found to have penetrated through the intestine4 ,thirdly1--,into a third portion of intestine was poured equal parts of sheep's bile1 and chyme obtained from a dog in full digestion1 through a #ah fistulous opening into its stomach4 ,after being treated for the same length of time1 and in precisely the same manner as the others1 evident signs of the oily matters of the chyme having passed through the walls of the intestine were obtained1 for they were seen as a scum floating on the surface of the albuminous water4 ,moreover1 the fatty matters were not in the form of pure oil1 but of a soapy substance4 ,the bile is thus seen to possess one of the more remarkable properties of the pancreatic juice4 ,there is this important difference between the action of these two secretions on fats1 however1 that while bile merely emulsions and saponifies that portion of our food which enters the duodenum in the form of fatty acids1 pancreatic juice1 on the other hand1 possesses the power1 not only of emulsioning and saponifying the fatty acids1 but also the neutral fats2 indeed1 its power seems chiefly to be exerted upon the latter4 ,hence it appears that both secretions are in a measure necessary to the complete digestion and absorption of the oleaginous constituents of our food4 ,on one occasion1 while experimenting with bile at ,university ,college1 ,i was surprised to hear ,minton1 the servant who was assisting me1 say1 that while he was travelling with ,sir ,andrew ,smith in ,south ,africa1 he had oftentimes seen the #ai ,caffres drink bile direct from the gall-bladders of the animals killed by the ,european party1 and that1 while passing the gall-bladder round to each other1 they would rub their stomachs and say1--,moo-ka-kolla1 signifying thereby1 that it was very good4 ,it certainly seems very extraordinary that any human being should not only drink1 but drink with pleasure1 a liquid so bitter and nauseating as bile4 ,perhaps the poor ,caffres1 however1 drank the sickening tasted bile for the same reasons as the cattle in ,caffreland1 at certain periods of the year1 go thousands of miles to drink at the salt-springs4 ,there being scarcely any chloride of sodium in the earth1 there is insufficient for the animal requirements in the herbage on which they feed1 and they are forced to supply the deficiency by artificial means4 ,bile contains a large percentage of soda1 and perhaps the ,caffres drink it in order to obtain that substance1 just as the animals drink the brackish water of the salt licks1 feeling that it agrees with them1 without knowing why4 ,,the ,,mechanism ,,of ,,jaundice4 ,as said in the beginning of this paper1 ,i believe1 the pathology of jaundice may be embodied under the two heads1 jaundice from suppression #bj of the biliary functions1 and jaundice from re-absorption of the secreted but retained bile4 ,these are at best1 however1 but vague terms1 and in order to make the pathology of jaundice somewhat more definite it will be necessary for me to subdivide these two great classes in the following manner3-- 7,,class ,a47--,,jaundice ,,from ,,suppression4 ,arising from3-- 7#a7 ,enervation4 7#b7 ,disordered hepatic circulation4 7#c7 ,absence of secreting substance4 7,,class ,b47--,,jaundice ,,from ,,re-,,absorption4 ,arising from3-- 7#a7 ,congenital deficiency of bile-ducts4 7#b7 ,accidental obstruction of bile-ducts4 ,i shall now try to point out the pathology of these different states1 and see how far they are able to explain the occurrence of jaundice under the various conditions already alluded to4 ,,jaundice ,,from ,,suppression4 ,although there can be no misunderstanding the meaning of the term jaundice from suppression1 there may1 nevertheless1 be some difficulty in comprehending how the skin becomes yellow1 and the urine high coloured1 when the secretion #ba of bile is arrested4 ,in order to explain how this occurs1 it will be necessary to recall to mind what was said regarding the nature of the biliary secretion4 ,it will be remembered that ,i began by saying1 that while some of the constituents of the bile are generated in the liver itself1 there are others that exist1 pre-formed in the blood4 ,if this view of the physiology of the biliary secretion be correct1 it is perfectly evident that when the secretion of bile is arrested1 those substances which the liver generates will be entirely wanting1 while those which it merely excretes from the blood will accumulate there as soon as their excretion is prevented2 just as urea accumulates in the circulation when its elimination by the kidneys is stopped4 ,hence it is that1 as soon as the biliary secretion is in abeyance1 biliverdine accumulates in the blood 7until the serum is as it were completely saturated with the pigment71 from which it exudes and stains the tissues1 and produces the colour we term jaundice4 ,at the same time1 or even before the skin becomes yellow1 the urine assumes a saffron tint in consequence of the elimination of the colouring matter by the kidneys4#h ,from this it will be seen that ,i regard #bb the yellow skin and high-coloured urine of jaundice as simply due to the deranged secretion of biliverdine1 quite independent of the presence or absence of the other constituents of the bile1 the effects produced by which will be referred to elsewhere4 ,meanwhile we shall separately consider the further pathology of the three subdivisions of jaundice arising from suppression4 ,footnote #h3 ,the true order of the occurrence of these changes is3--,on the second day the urine becomes high-coloured2 in a day or two later the skin assumes a yellow tint2 and1 in very severe cases1 within the first week or two1 the sweat1 the milk1 the tears1 the sputa1 and the serum in the thoracic and abdominal cavities1 become of a more or less decided yellow hue4 ,,jaundice ,,as ,a ,,result ,,of ,,enervation4 ,it is now a well-established fact that all secretions are under the direct influence of the nervous system4 ,stimulate a nerve supplying a gland1 and secretion is accelerated2 stop the nervous action1 and secretion is as instantaneously arrested4 ,again1 just in the same way as volition can produce or suspend muscular movement1 mental influence can hasten or retard glandular secretion4 ,as an illustration of this fact1 ,i need only call to mind the influence the mere sight of food has in exciting the salivary secretion1 and the effect of bad news in arresting it4 ,exactly the same influence as is here alluded to1 is exerted by the mind over the biliary function4 ,if1 for example1 #bc as ,bernard first observed1 a dog with a biliary fistula be caressed1 the secretion of bile is actively continued2 if1 on the other hand1 the animal be suddenly ill-used1 the secretion of bile is instantly arrested4 ,if he be again caressed1 the secretion is re-established1 and the bile flows drop by drop from the end of the cannula4 ,here the influence is entirely produced through the intervention of the nervous system2 and if such effects as are above described occur in the dog1 we can surely have little difficulty in understanding how the biliary secretion can be influenced in the highly-developed organization of the human being4 ,indeed1 every one must have felt how quickly sad tidings received during a meal not only destroy the appetite and retard digestion1 but occasionally alter the complexion4 ,this effect1 that all of us must have experienced in a slight degree in our own persons1 several may have observed to a greater extent in the persons of others1 even to the production of well-marked jaundice4 ,at this very time ,i have under my care a young married lady1 who during the last two years has twice suffered from an attack of jaundice induced by witnessing her child in convulsions1 and this ,i regard as an example of jaundice from enervation4 ,one of the reasons1 no doubt1 why jaundice does not more frequently follow upon mental emotion is #bd simply on account of a certain amount of pigment being required in order to produce a visible tinging of the body1 and it seldom happens that the emotional effect on the biliary secretion is sufficiently permanent to permit of the requisite amount of pigment accumulating in the blood4 ,the reason1 too1 why mental emotion is more apt to cause jaundice immediately after a meal is1 as will afterwards be better understood1 on account of the congested state of the liver at that time favouring the stoppage of the secretion4 ,a blow on the head1 which is now and then observed to be suddenly followed by jaundice1 acts1 ,i believe1 in the same way as fright1 namely1 by paralyzing the nerve force required for the continuance of the biliary secretion4 ,i now pass on to the consideration of the pathology of the second kind of jaundice from suppression1 namely1 jaundice resulting from hepatic congestion4 ,,jaundice ,,arising ,,from ,,hepatic ,,congestion4 ,this is one of the most common causes of the disease2 but as there are two kinds of hepatic congestion--active and passive--it will be necessary for me to make a further subdivision1 and consider each of these separately4 #be ,jaundice the ,result of ,active ,congestion4 ,the mechanism of jaundice resulting from active congestion of the liver is readily explained on physiological grounds4 ,the congested condition of any gland is unfavourable to secretion4 ,we all know1 for example1 that congestion of the kidney is accompanied by a suppression of the urinary secretion1 and that the secretion is re-established as the congested condition of the organ diminishes4 ,the suppression of the renal secretion is no doubt due to the engorged capillaries pressing upon the secreting structure1 and ultimate ramifications of the urine tubes1 and thereby annulling their functions4 ,a similar explanation is equally applicable to the biliary secretion2 and just as it happens in the case of the kidney1 that it is exceedingly rare for a total suppression of its functions to take place1 so with the liver it seldom happens that the congestion is sufficiently severe to induce complete arrest of the biliary secretion4 ,we find1 therefore1 that although there may be yellowness of the skin and high-coloured urine in such cases1 pipe-clay stools are frequently absent1 sufficient bile to tinge the fces still finding its way into the intestines4 ,undoubtedly it must have occurred to many of my readers1 that jaundice is frequently absent in #bf cases of acute inflammation of the liver1 even running on to suppuration1 and that the foregoing theory of the pathology of such cases is therefore insufficient4 ,at one time ,i was puzzled to explain this apparent anomaly1 but on subsequent investigation the true cause became apparent1 and instead of the above fact detracting from1 it tended rather to strengthen the theory4 ,if1 for example1 we closely examine cases of acute hepatitis without jaundice1 we find they are those in which only a portion of the liver is affected4 ,it matters not whether it be one lobe or two1 the surface or the centre of the organ1 the disease is invariably circumscribed2 and there is enough hepatic tissue left in a sufficiently normal condition to prevent the constituents of the bile accumulating in the blood1 and producing jaundice4 ,this may even occur1 as ,i have myself observed1 when the disease has run on to suppuration4 ,the most typical example of jaundice as the result of active congestion1 is to be found in those cases where it supervenes on an attack of hepatitis1 such as is met with in hot climates1 where indolent habits and high living favour portal congestion4 ,it is occasionally met with in ,england1 however1 and is frequently associated with gastric derangement4 ,i had occasion to witness a good example of #bg this form of disease in the person of a ,french gentleman1 who was brought to me seven days after his arrival in ,england1 on account of his skin having assumed a most intense yellow hue4 ,it appeared that he had come to ,england on a visit to some of his friends1 and rather enjoying the novelty of an ,english table1 indulged too freely in a quantity and quality of food to which he had hitherto been a stranger4 ,the consequence was1 that within three days after his arrival he began to suffer from hepatic tenderness1 and dyspeptic symptoms2 the skin at the same time assumed a dusky hue1 which soon merged into a decided yellowness4 ,these symptoms were accompanied by pipe-clay stools and saffron-coloured urine2 on the latter being tested it gave a distinct bile pigment1 but no bile acid reaction--a point which ,i shall afterwards have occasion to show1 is of a certain diagnostic value in obscure cases of jaundice4 ,this gentleman1 under the influence of benzoic acid1 perfectly recovered his normal complexion in the short space of a week4 ,there is another form of jaundice from active congestion1 viz41 that due to the presence of zymotic disease1 such as ague1 typhus1 and other fevers4 ,as an illustration of this kind of affection1 ,i shall cite one arising from the first of these causes1 namely1 ague4 ,and the best example ,i #bh can give is one that has recently fallen under my notice1 and which occurred in the person of a member of our own profession4 ,the gentleman was for several years surgeon to one of our large colonial hospitals1 but in consequence of repeated attacks of intermittent fever1 was forced to resign the appointment1 as well as a lucrative practice1 and return to ,england4 ,he has now been at home for two years1 and although his general health has much improved1 still suffers from occasional attacks of his old enemy4 ,on consulting me regarding his case several months ago1 he mentioned1 that while suffering from the above-named attacks1 he occasionally suddenly passed five or six ounces of urine as dark as chocolate1 and this would recur perhaps once in twenty-four hours1 during two or three days1 and then as suddenly disappear4 ,this urinary symptom being an unusual one1 ,i requested him to send me on the next occasion a specimen of the fluid4 ,in the beginning of last ,november#i ,i received three samples of urine1 one passed at eight ,a4,m41 which was clear1 pale1 of a specific gravity of #ajbe1 of an acid reaction1 deposited no lithates1 and contained no albumen1 being in fact normal in every respect2 another quantity passed at two ,p4,m41 of #bi a chocolate brown colour1 opaque1 turbid1 having a specific gravity of #ajcb1 of an acid reaction1 depositing lithates1 containing albumen1#aj some sugar1 and a large excess of urea 7#cf per cent47 and urohmatine2 a third sample passed at night1 of a specific gravity of #ajba1 also with an acid reaction1 depositing lithates in small quantity1 but containing no albumen4 ,the percentage of urea in this urine was exactly one-half 7namely1 #ah7 of what it was in the preceding specimen passed at two ,p4,m4 ,footnote #i3 ,this was written last year1 and therefore refers to ,november1 #ahfa4 ,footnote #aj3 ,when examined with the microscope1 this specimen of urine was found to contain a large quantity of nucleated epithelium1 and granular cells2 free granules of a hmatine colour1 granular tube-casts1 and a quantity of mucus2 while the morning and evening urines were perfectly free of any such substances4 ,the varying conditions of these three urines clearly pointed to intense congestion of the chylopoietic viscera1 of a transient and periodic character4 ,suiting the practice to the theory1 mercurials were taken by this gentleman in order to remove the congestion of the chylopoietic viscera1 and with the most favourable results1 for1 as ,i afterwards learned1 the jaundice and other disagreeable symptoms soon disappeared4 ,jaundice the ,result of ,passive ,congestion of the ,liver4 ,in this case the congestion1 instead of arising from an increased flow of blood to the liver1 as #cj in the preceding1 is the result of some cause impeding the outward flow of blood from the liver4 ,thus for example1 passive hepatic congestion may arise from valvular disease of the heart1 or from any pulmonary affection obstructing the circulation of blood through the lungs 7pneumonia1 c474 ,jaundice from the passive form of hepatic congestion1 is not so common as jaundice from the active form1 in consequence of the former being1 as a rule1 much slighter than the latter4 ,its pathology is1 however1 ,i believe1 exactly the same1 viz4 the result of the engorged hepatic capillaries compressing the secreting cells and tubes1 and thereby annulling their functions4 ,such being the case1 it is unnecessary for me to do more than merely allude to this cause of jaundice4 ,it may1 perhaps1 be asked--,if the foregoing statements regarding the pathology of jaundice from congestion be correct1 how does it happen that it is not present in every severe case of gastric derangement1 fever1 heart-disease1 c48 ,this question is easily answered1 for as ,dr4 ,budd has clearly put it1 while speaking of the action of medicines upon the liver--,in most persons1 perhaps1 a portion of the liver may waste or become less active without sensible derangement of health1 they have more liver1 as they have more lung1 than is absolutely necessary4 ,in others1 on the #ca contrary1 the liver1 from natural conformation1 seems just capable of effecting its purpose under favourable circumstances4 ,persons inheriting this feebleness of liver1 or in whom1 in consequence of disease1 a portion of the liver has atrophied1 or the secreting element of the liver has been damaged1 may suffer little inconvenience as long as they are placed in favourable circumstances1 and observe those rules which such a condition requires2 but as soon as the balance of their hepatic circulation is disturbed by causes like those above mentioned1 jaundice makes its appearance2 such patients being1 as ,dr4 ,budd says1 born with a tendency to bilious derangements4#aa ,footnote #aa3 ,diseases of the ,liver1 p4 #ee4 ,,jaundice ,,as ,a ,,result ,,of ,,suppression ,,consequent ,,upon ,,absence ,,of ,,the ,,secreting ,,substance4 ,the pathology of this state is self-evident1 for wherever secreting substance is wanting1 secretion cannot take place4 ,if then1 the tissue which secretes bile be destroyed or transformed by disease1 the biliary function must be suspended1 and the ingredients which it is the office of such structure to separate from the blood1 will accumulate in the circulation1 and give rise to the #cb usual chain of results following suppression of the biliary secretion4 ,in cancer1 tubercle1 fatty and amyloid degeneration of the liver1 jaundice arises from the above-named cause4 ,in these diseases it is not1 however1 a constant symptom1 and this is simply on account of there being usually sufficient healthy tissue left to enable the biliary secretion to be carried on4 ,if the cancer1 or other morbid product1 occupied the whole place of the secreting tissue1 the biliary function could no more be carried on by such product1 than by the same product occupying another organ of the body4 ,in cases of jaundice arising from absence of the secreting substance1 the amount of the jaundice depends on another cause besides the mere extent of the morbid deposit4 ,this is its situation4 ,a large amount of diseased tissue may exist in certain portions of the liver1 and yet fail to produce jaundice1 while a much smaller amount of the same diseased tissue1 placed in another situation1 may induce it4 ,should the morbid deposit1 for example1 be so placed as readily to interrupt the flow of the secreted bile1 jaundice may rapidly occur1 and be due as much to the re-absorption of the secreted bile1 as to the suppression of the biliary secretion4 ,this is1 indeed1 the true explanation of the fact1 that diseases affecting the #cc concave1 are much more frequently accompanied with jaundice1 than those attacking the convex surface of the liver4 ,i might have chosen what at first sight appears a more typical example of absence of secreting structure1 namely1 a case of acute atrophy of the liver2 for in such cases the hepatic tissues sometimes dwindle down in the course of a few days to less than a quarter of their original bulk1 and give rise to intense jaundice4 ,but in such cases there does not appear to be a total arrest of the secretion1 until the very last stage of the disease1 if it even occurs then2 and besides1 if ,i dare form an opinion from one case1 ,i should say that1 in consequence of the rapid disorganization of the parenchyma of the liver1 the circulation in the organ becomes much disturbed1 and gives rise to what ,frerichs terms disordered diffusion4 ,so that in cases of acute atrophy of the liver1 the jaundice1 although chiefly due to suppression1 is complicated with re-absorption of the bile1 as was proved in a case ,i examined1 by finding in the urine1 not only those products which are merely excreted from the blood1 but also some of those which are generated in the liver itself4 ,it will be necessary for me1 therefore1 to go more fully into this form of jaundice than ,i have done in any of the preceding forms of the disease4 #cd ,,jaundice ,,arising ,,from ,,acute ,,atrophy ,,of ,,the ,,liver4 ,acute1 or yellow atrophy of the liver1 is one of the most formidable of human diseases4 ,it is sudden in its onset1 rapid in its course1 fatal in its termination4 ,it is more common in women than in men2 seldom attacks those above thirty years of age1 and occurs most frequently in the earlier months of pregnancy4 ,the immediate exciting cause of this strange disease appears to be1 in the majority of cases1 mental depression4 ,the symptoms usually observed are jaundice1 rapidly followed by sickness1 and vomiting2 by febrile excitement1 and cerebral disturbance4 ,as the disease advances1 the hepatic dulness diminishes2 the urine becomes scanty1 and high-coloured2 the bowels confined4 ,extravasations of blood take place under the skin2 and hmorrhages from the nose1 vagina1 or bowels are frequently observed4 ,lastly1 delirium1 or coma1 generally closes the scene1 within a week after the commencement of the violent symptoms1 and within a month after the appearance of simple jaundice4 ,frerichs1 who has so well described these cases1 even says1 that in the severest forms1 the disease may run its course1 and end fatally within twenty-four hours4#ab ,footnote #ab3 ,clinical ,treatises on ,diseases of the ,liver1 vol4 i4 p4 #aig4 #ce ,all cases of acute atrophy of the liver are1 fortunately1 not necessarily fatal4 ,in some the violent symptoms gradually disappear1 and recovery takes place after free evacuation of the bowels4 ,in every case of suspected acute atrophy of the liver1 the urine ought to be carefully examined for tyrosine1 and leucine1 two abnormal products1 which1 according to ,frerichs1 are never absent4 ,some remarks on the diagnostic value of these substances will be found at page #fb4 ,through the kindness of ,dr4 ,wilks1 ,i had the opportunity of examining the liver1 and analysing the urine1 in a typical case of acute atrophy1 which he reported in the ,pathological ,society's ,transactions1 vol4 xiii4 p4 #ajg4 ,the brief history of the case is as follows3--,e4 ,k41 aged seventeen1 a married woman1 in the third month of pregnancy1 was seized with a bilious attack1 and jaundice1 after having a violent quarrel with her husband1 who accused her with infidelity4 ,the patient was first under the care of ,mr4 ,bisshopp1 of ,south ,lambeth1 who found her suffering from jaundice1 accompanied by some febrile symptoms1 and vomiting4 ,in two days she became delirious1 had violent screaming1 and convulsive fits1 which were rapidly followed by unconsciousness4 ,next day the patient was seen by ,dr4 ,wilks2 she was then quite insensible1 with slight stertorous breathing1 #cf and foam on the lips4 ,the pupils were moderately dilated1 and sensible to light4 ,the pulse #abj4 ,the hepatic dulness reduced to a narrow band over the lower ribs4 ,no urine had passed for twenty-four hours2 a catheter was therefore introduced1 and twelve ounces of clear bilious-looking fluid were drawn off4 ,this urine ,i had the opportunity of analysing a few days afterwards4 ,it was then of a yellow-ochre colour1 and contained a considerable deposit4 ,the analysis gave3 ,specific gravity 4 4 4 4 4 4 4 4 4 4 4 4 4 #ajbh ,reaction 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 acid 787 ,,in #ajjj ,,parts4 ,water 4 4 4 4 4 4 4 4 4 4 4 4 #idhhfj ,solids 7organic1 inorganic7 4 #eaach ,urea 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 #cjjjj ,uric acid 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 #jcge ,resin and mucus 4 4 4 4 4 4 4 4 4 ,bile1 colouring matter1 and acids ,urohmatine 4 4 4 4 4 4 4 4 4 4 4 4 4 4 #adege ,leucine1 and tyrosine 4 4 4 4 4 4 ,inorganic salts 4 4 4 4 4 4 4 4 4 4 4 4 4 #fahh ,the biliary acids 7contrary to what ,frerichs found in some of his cases7 were present in this urine in fair quantity4 ,with ,pettenkofer's test 7sulphuric acid and sugar7 a decided purple colour was obtained4 #cg ,when a portion of the urine was concentrated1 and allowed to crystallize slowly1 beautiful crystals of both tyrosine1 and leucine were detected in it by means of the microscope4 ,the purified urine also showed the presence of sugar in small quantity4 ,when the organic solids were burned1 they had a strong odour1 and gave off a smoky flame1 thereby showing that the urine contained a considerable quantity of fatty resin4 ,as calculating the constituents of the urine by percentage is a very unsatisfactory method for scientific purposes1 it may be useful for me to give the analysis of the same urine as calculated for twenty-four hours1 viz41 twelve ounces1 the amount drawn from the bladder shortly before death4 ,in that case the analysis gives3 #bd ,,hours' ,,urine4 ,quantity 4 4 4 4 4 4 4 4 4 4 4 4 4 #cgbjj c4c4 ,specific gravity 4 4 4 4 4 4 4 4 4 #ajbh ,reaction 4 4 4 4 4 4 4 4 4 4 4 4 4 acid 787 ,solids 7total7 4 4 4 4 4 4 4 4 4 4 #aijch grammes4 ,urea 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 #aaafj ,uric acid 4 4 4 4 4 4 4 4 4 4 4 4 #jaci ,resin1 and mucus 4 4 4 4 4 4 ,bile pigment1 and acids 4 4 ,urohmatine 4 4 4 4 4 4 4 4 4 4 #edda ,tyrosine1 and leucine 4 4 4 ,inorganic salts 4 4 4 4 4 4 4 4 4 #bbih ,during the night before her death1 the patient #ch aborted1 and lost a considerable quantity of blood by the vagina4 ,the whole duration of the disease was merely six days1 and the more urgent symptoms only manifested themselves two days before the fatal termination4 ,after death the liver was found to be very small in size1 not exceeding1 as was supposed1 #a pound in weight4 ,it was deeply stained yellow1 and its cells were found to be small1 and broken up2 not an entire cell could be detected by either ,dr4 ,wilks or myself--nothing1 indeed1 but a quantity of dbris of hepatic tissue1 and fat4 ,the gall-bladder was contracted1 and contained only a little mucus2 the urinary-bladder was empty4 ,although jaundice the result of acute atrophy of the liver1 might be thought to be a typical example of jaundice arising from a suppression of the biliary function--the diminution in secreting substance naturally inducing a diminution in secreting power--,i have1 as was before said1 been led to view it differently2 because1 although less bile than usual is secreted1 there is nevertheless nothing like an entire suppression of the biliary function1 as is proved1-- ,firstly1--,by the absence of pipe-clay stools4 ,secondly1--,by the deep staining of the hepatic tissue with bile pigment1 just as occurs in jaundice the result of obstruction4 #ci ,thirdly1--,by the presence of the biliary acids in the urine4 ,fourthly1--and lastly1 the violent symptoms of bile-poisoning lead to the same conclusion1 for it is not bile pigment1 but the bile acids1 that induce the fatal symptoms of bile-poisoning4#ac ,footnote #ac3 ,six grains of pure glycocholate of soda killed a small dog1 into whose femoral vein ,i injected it1 in the course of two hours4 ,in experimenting on animals1 ,i have made the curious observation1 that although bile has the property of retarding or arresting putrefaction1 both in the intestinal canal1 and out of the body1 yet1 when injected into the subcutaneous cellular tissue of a healthy animal1 it causes the surrounding tissues to decompose1 and become foetid1 and an artificial disease is thereby set up1 whose most peculiar feature is the engendering of a rapid putrefaction of the body after death4 ,,class ,b4 ,,the ,,mechanism ,,of ,,jaundice ,,arising ,,from ,,the ,,re-,,absorption ,,of ,,the ,,secreted1 ,,but ,,retained ,,bile4 ,in cases of this kind1 the obstruction is not usually to be found within the liver itself1 but in the ducts after their exit from the hepatic organ4 ,the seat of the obstruction1 too1 is much more frequently found near to1 or at the termination of the common duct1 than close to the liver4 ,the obstruction may be of three kinds3-- #dj ,firstly1--,a congenital deficiency of the bile-ducts4 ,secondly1--,an accidental obstruction in the course of the ducts1 as from gall-stones1 hydatids1 or the entrance of foreign bodies from the intestines4 ,thirdly1--,from closure of the outlet of the common duct1 as1 for example1 from the pressure of the pregnant uterus1 or distended transverse colon1 or from organic disease of the pancreas1 or neighbouring organs4 ,first1 as regards cases of jaundice from congenital deficiency of the ducts4 ,cases of this kind are rare4 ,the best with which ,i am acquainted is the one that was brought before the ,pathological ,society last year1 by ,dr4 ,wilks4 ,the child had never passed any meconium1 the motions always being of a white colour4 ,when a fortnight old1 jaundice came on1 and continued until death1 at the age of six weeks4 ,after death1 the liver was found of a dark green colour1 and1 apparently1 the gall-bladder was absent4 ,on further examination1 however1 the cellular tissue1 which appeared to occupy its place1 was found to be occupied by a small canal1 just large enough to contain a bristle2 to this1 however1 no outlet could be found1 and on endeavouring to discover the hepatic ducts1 these1 in like manner1 could not be made #da out4 ,the opening of the common duct in the duodenum was natural1 but no hepatic duct could be found joining the pancreatic4 ,it appeared1 therefore1 as if the larger ducts had become shrunken and obliterated4#ad ,footnote #ad3 ,medical ,times and ,gazette1 #bith ,march1 #ahfb4 ,through the kindness of ,dr4 ,wilks1 ,i had the opportunity of making a microscopical examination of the liver4 ,the hepatic cells were very small in size1 much broken up2 very few possessed nuclei1 and all were deeply tinged with brownish yellow colouring matter4 ,scattered throughout the hepatic tissue1 ,i found numbers of well-formed cholesterine crystals1 like those represented in ,fig4 #c4 ,i must here mention1 that jaundice does not necessarily follow upon absence of the gall-bladder2 just as in the horse1 the deer1 the rat1 and other animals that possess no gall-bladders1 the biliary function is perfectly well carried on1 so it may be in the human subject1 labouring under a congenital or accidental deficiency of the gall-bladder4 ,in such cases1 the hepatic ducts are pervious1 and consequently the secreted bile finds no difficulty in reaching the intestines4 ,in the ,edinburgh ,medical ,journal 7,may1 #ahfa1 p4 #ajde17 ,dr4 ,alexander ,simpson reports a case of #db this kind occurring in a child1 which died when only a few weeks old4 ,there was no trace of the existence of a gall-bladder2 but on laying open the duodenum1 the orifice of the bile-duct was at once seen in its ordinary situation1 and a drop of pale bile was expressed from it4 ,on tracing the duct to the liver1 it was found to pass up undivided into the horizontal fissure1 where it at once broke up and branched into the hepatic tissue of the right1 and left lobes4 ,i shall delay entering into an explanation of the mechanism of jaundice from obstruction1 until ,i come to the consideration of what may be termed ,permanent ,jaundice1 as in that case one explanation will do for all4 ,,jaundice ,,as ,a ,,result ,,of ,,the ,,accidental ,,obstruction ,,of ,,the ,,bile-,,ducts4 ,the second class of cases1 namely1 those in which the obstruction is in the course of the ducts1 are of frequent occurrence1 and in them the jaundiced state is usually merely transient1 for no sooner has the obstruction been removed1 than the jaundice begins to disappear4 ,the most common cases of this kind are those arising from gall-stones4 ,as every one is familiar with their history1 ,i may merely mention1 that we may have gall-stones1 and even all the most painful #dc symptoms of gall-stones1 without the slightest trace of jaundice4 ,this1 ,i believe1 arises in the following manner3-- ,firstly1--,the majority of gall-stones are formed in the gall-bladder2 their formation being due to the accidental deposition of the less soluble parts of the bile1 either as a consequence of these ingredients being present in excess1 or in consequence of the solvent1 whose duty it is to retain them in solution1 being in reduced quantity4 ,the deposition or formation of gall-stones follows exactly the same law as the deposition or formation of stone in the bladder4 ,secondly1--,in some cases the gall-stone1 or stones--for there may be many1 even hundreds1 remain in the gall-bladder during the whole life of the individual1 without giving rise to any disagreeable results1 either as regards pain1 or jaundice4 ,in other cases1 the gall-stones--and this usually happens when they are small--get into the cystic duct1 and become lodged there2 and in such a case1 although the patient may suffer intense pain1 there is still no jaundice4 ,moreover1 it is not until the stone or stones have passed down into the common bile-duct1 that jaundice is at all likely to be induced by them4 ,for while a stone remains in the cystic duct1 although it may completely block it up1 and effectually prevent the bile either #dd entering into or escaping from the gall-bladder1 yet1 as in this situation it cannot offer any obstacle to the direct flow of the biliary secretion from the hepatic tissue into the intestines1 there is no retention1 and consequent absorption of bile4 ,in fact1 the presence of the stone in this position1 in as far as the biliary function is concerned1 only reduces the patient to the state of a person in whom the gall-bladder is accidentally absent2 or to that of a horse1 or other animal1 in which the absence of the gall-bladder is a normal condition4 ,thirdly1--,there are yet other ways in which gall-stones may give rise to great discomfort1 and even imperil life1 without inducing jaundice4 ,for example1 a calculus may remain in the gall-bladder until it attains a very large size1 and then ulcerate its way into the stomach1 intestines1#ae peritoneal cavity1 or even out of the body through an opening in the abdominal parietes4#af ,footnote #ae3 ,vide a case of this kind published by the author in the ,pathological ,society's ,transactions for #aheg1 p4 #bce4 ,footnote #af3 ,vide a case published by ,mr4 ,hinton in the ,brit4 ,med4 ,journ4 of ,august #dth1 #ahfj1 p4 #fjc1 and one by ,mr4 ,sympson in the same ,journal of the #gth ,february1 #ahfc1 p4 #aci4 ,in fact1 jaundice only appears as a complication of gall-stones when they chance to block up the common duct1 and thereby prevent the bile entering the intestinal canal4 ,hence1 also1 the reason #de why jaundice1 as a result of gall-stones1 is more frequently transient than permanent4 ,if it chances to become permanent1 it sooner or later leads to a fatal termination--usually within eighteen months after complete obstruction4 ,lastly1 it may be mentioned that1 although gall-stones are liable to form in almost every constitution1 yet it is generally considered that they are most frequent in persons of the tubercular1 cancerous1 and gouty diathesis1 either hereditary or acquired4 ,there are other substances besides gall-stones which1 by their accidental presence in the bile-ducts1 may give rise to jaundice4 ,thus1 for example1 foreign bodies1 such as cherry-stones1 have found their way from the intestine into the bile-duct1 and given rise to jaundice4 ,intestinal worms have been observed to do the same thing1 and recently an interesting case of jaundice1 occurring in a girl aged #af1 who died after a few weeks' illness1 has been reported1 which resulted from the presence of hydatids in the ductus hepaticus1 and ductus communis choledochus4#ag ,hydatids of the liver itself seldom give rise to jaundice1 their position being usually such as not to interfere with the biliary function4 ,footnote #ag3 ,dr4 ,dickinson has reported this case in the ,pathological ,society's ,transactions1 p4 #ajd1 vol4 xiii4 #ahfb4 ,there are still other cases where we find #df transient jaundice arising from accidental obstruction of the bile-ducts2 but in them1 instead of the closure of the ducts resulting from plugging from within1 it arises from the application of pressure from without4 ,thus1 for example1 transient jaundice is met with as the result of closure of the common bile-duct1 by pressure exerted upon it by the pregnant uterus1 or by impacted fces in the transverse colon4 ,certain permanent abdominal tumours may also lead to the same result1 but these will with greater propriety be considered under the next head4 ,,permanent ,,jaundice ,,from ,,obstruction4 ,in order to give as clear a view as possible of the pathology of permanent jaundice from obstruction1 it will be necessary for me to give the history of a case of closure of the outlet of the common bile-duct in consequence of organic disease--such1 for example1 as cancer of the head of the pancreas4 ,a case of this kind has the further advantage of at the same time furnishing us with a typical example of jaundice arising from the re-absorption of the secreted1 but retained bile4 ,when cancer of the head of the pancreas involves the orifice of the common bile-duct1 as the tumour grows1 the duct slowly1 and gradually becomes impervious to the passage of bile into the #dg intestines1 until at length the flow is completely arrested4 ,as this gradual process of occlusion of the outlet goes on1 the duct itself becomes more and more distended by the retained bile1 till it at length attains an enormous size4 ,the gall-bladder being equally prevented from emptying itself1 likewise becomes stretched and dilated1 until it may at last become not only palpable to the touch1 but even apparent to the eye through the abdominal walls4 ,this was the case in the patient whose liver1 and occluded ducts are represented in ,plate ,i4 ,the distention of the bile-ducts is not limited to those situated external to the liver1 but also affects those in the substance of the organ2 and to such an extent may this be the case1 that1 on making a section of a liver that has long had its common duct obstructed1 a number of large excavations are observed all over its surface1 which excavations are nothing more than the open mouths of the transverse sections of the dilated ducts4 ,such a state of matters is tolerably well represented in the section of the liver in ,plate ,i4 ,further1 the effect of this obstruction to the exit1 and consequent accumulation of the biliary secretion1 is not confined to the mere distention of the ducts1 but causes various changes to occur in the parenchyma of the liver itself4 ,the first of these is an increase #dh in the size of the organ1 arising partly from the accumulation of the bile1 and partly from the congestion caused by the pressure exerted on the vessels by the distended ducts4 ,in the second place1 gradually as the state of matters here described progresses1 the parenchyma of the organ becomes itself affected1 partly from the direct pressure exercised upon it1 and partly from the derangement of its nutrition1 produced by the interruption to the hepatic circulation2 so that1 after a time1 the enlarged liver slowly1 and by degrees diminishes1 until it at length regains its natural size1 thereby rendering1 at this period of the disease1 the diagnosis of the case extremely difficult4 ,this state of matters is not1 however1 of long duration2 for1 in consequence of the continued compression of the blood-vessels and parenchyma1 the nutrition of the liver is so disordered1 as to lead to a gradual shrinking of the entire substance1 or1 in other words1 to a general atrophy of the organ4 ,it is thus seen how in permanent occlusion of the common gall-duct the liver may be found hypertrophied in the first1 of normal dimensions in the second1 and atrophied in the third and last stage of the disease4 ,in cases of the kind here described1 it is not at all unlikely that the enlargement of the liver in the earlier1 as well as its atrophy in the later #di stages of obstruction1 may be mistaken for the cause of the jaundice1 instead of the result of the arrest of the flow of bile1 and thereby lead to a grave error in treatment4 ,the history of the case1 together with a knowledge of the above facts1 will1 however1 tend to facilitate the diagnosis4 ,thus1 it must be ascertained3-- ,firstly1--,if the jaundice preceded the alteration in size of the organ4 ,secondly1--,if there is an absence of any history of hepatitis2 and1 ,thirdly1--,if there is no evidence of any pulmonary or cardiac mischief likely to lead to passive congestion of the hepatic tissue4 ,even with a knowledge of all these facts1 however1 it often baffles the skill1 and acumen of the ablest physicians to discover the cause of jaundice4 ,every now and then cases are met with1 where the patient tells us that the jaundice has gradually come on without any assignable cause1 and where1 after the most careful examination of his history1 as well as of his physical condition1 we fail to detect a clue to the diagnosis4 ,cases of this kind are far from uncommon1 and this is the more to be regretted1 seeing that unless we have a clear appreciation of the cause1 it is not only difficult1 but even dangerous to treat the symptom4 ,the injudicious administration of #ej a remedy here1 may hasten the termination we most desire to retard4 ,the truth of this remark will1 however1 be better appreciated when ,i come to consider the rationale of the treatment of jaundice4 ,meanwhile1 it may be advisable to point out a method capable of yielding most important information1 when all the ordinary means of diagnosis fail4 ,i allude to the chemistry of the excretions4 ,although the pathological chemistry of the excretions is as yet in its infancy1 it has already given the scientific physician a key to the detection of several diseases1 and ,i trust to be able to show1 that even in the obscure cases of jaundice above alluded to1 it not only gives us a clue to their cause1 but presents us with a guide to their treatment4 ,in jaundice arising from obstruction1 the pipe-clay stools are1 as in the case of jaundice from suppression1 entirely due to the absence of bile from the intestinal canal4 ,the yellowness of the skin is in like manner caused by the accumulation of the bile pigment in the blood1 from whence it exudes1 and stains the tissues2 and1 lastly1 the saffron-coloured urine results in a similar way from the elimination of the pigment from the blood by the kidneys4 ,instead1 however1 of these three conditions arising1 as in the case of jaundice from suppression1 from the arrest of the biliary functions #ea allowing certain of the constituents of the bile to accumulate in the circulation1 they are1 in the first place1 the result of the re-absorption of the secreted bile from the distended ducts1 and gall-bladder4 ,so that while in jaundice from suppression1 only those biliary products which exist pre-formed in the blood accumulate in the circulation1 in cases of jaundice from obstruction1 the biliary products which are manufactured in the liver1 equally with those which are pre-formed in the blood1 find their way back into the circulation1 to be from thence eliminated with the excretions4 ,if then1 we could ascertain the presence or absence of these products in the excretions1 we should be enabled to distinguish between jaundice resulting from suppression1 and jaundice arising from obstruction4 ,let us now see what the chemistry of the excretions teaches us2 and to begin1 we shall take the intestinal excretion4 ,,analysis ,,of ,,the ,,intestinal ,,excretion ,,as ,,an ,,aid ,,to ,,the ,,diagnosis ,,of ,,obscure ,,cases ,,of ,,jaundice4 ,the intestinal excretion1 in the natural state1 consists1 firstly1--of those portions of our food which have resisted the action of the digestive juices2 secondly1--of the excess of the modified food remaining unabsorbed2 and1 thirdly1--of the excess1 #eb as well as of the effete portions of the digestive secretions themselves4 ,consequently1 if from any cause the digestive secretions do not act properly1 the evacuation immediately becomes abnormal1 and we can discover by analysis which of the secretions is at fault4 ,thus1 for example1 we know that the saliva acts upon the starchy matters of our food1 the gastric juice on the albuminous1 the pancreatic on the fatty1 and that the biliary secretion so modifies the chyme as to allow of its rapid absorption by the lacteal1 and portal vessels4 ,if then1 from any cause the elaboration1 or excretion of any of these digestive juices be interfered with1 more of the particular kind or kinds of food on which it acts1 passes unchanged through the intestines4 ,thus1 if the salivary secretion be affected1 an unusual amount of unmodified starch is found in the stool4 ,if the gastric juice is defective1 more albumen than is normal passes away unchanged1 and so on with the others4 ,it is clear then1 that an examination of the stools must afford us important information regarding the presence1 or absence of the normal secretions4 ,a simple inspection of the stool will sometimes at once tell us whether or not bile is present4 ,if it be present1 the stool varies from a pale yellow1 to a dark olive-green hue1 according to the kind1 and quantity of biliary colouring matter present1 and #ec the nature of the food4 ,it must not be forgotten however1 that unless care be taken1 the colour deducible from highly-coloured food may be mistaken for an excess of bile4 ,this remark is still more applicable to medicines1 for mercury1 bismuth1 iron1 and some other mineral remedies1 give rise to dark evacuations so closely resembling bilious stools in appearance1 that the only way to distinguish them1 is by chemical analysis2 when1 the presence of the mineral1 together with the absence of the bile pigment1 and the biliary acids 7which are always to be found in normal evacuations71 will at once reveal the true nature of the case4 ,i have seen a mistake of this kind happen1 and that too1 where a patient labouring under jaundice from obstruction1 was thought to be passing the usual amount of bile in his stools1 when in reality not a particle of bile pigment was present4 ,the colour was in this case entirely due to the food1 and ferruginous remedies4 ,blood from the stomach or bowels1 is also apt to be mistaken for biliary matter1 more especially when acted on by the gastric juice1 which has the property of turning red blood brown4 ,with these exceptions1 the absence of bile from the stool1 is usually very easily ascertained4 ,for if the patient be taking no highly-coloured food1 or any of the medicines above indicated1 the stools are of a #ed dirty pipe-clay colour4 ,this is not due to the presence of any new or foreign matter1 but solely to the absence of bile pigment4 ,in these cases the evacuations1 besides being white1 are usually of a most offensive odour1 for1 among other things1 bile checks intestinal putrefaction1 and the development of offensive gases4 ,in addition to the colour1 and odour of the fces1 in cases of jaundice1 another important indication is to be found in the presence of fat4 ,the presence of fat in the stools was at one time looked upon as evidence of pancreatic1 at another time of hepatic disease2 now1 however1 experimental physiology has taught us1 that it in some measure depends upon both4 ,for while1 on the one hand1 the pancreatic secretion emulsions the fatty part of our diet1 and thereby renders it capable of absorption1 recent researches1 as has been already pointed out1 have established the fact that the biliary secretion also plays an important part in the absorption of the oleaginous constituents of our food4 ,bidder and ,schmidt1 as was before said1 have shown that a dog1 after ligature of the gall-duct1 absorbs less than half the average normal quantity of fat2 and by experiment it has been found that this arises from the circumstance that bile emulsions only the acid fats1 while pancreatic juice transforms the neutral as well as the acid #ee oleaginous matters4 ,the presence of fat in the stools may be due1 therefore1 partly to hepatic1 partly to pancreatic derangement2 and ,i shall immediately point out how we can turn this fact to account in diagnosis1 and discover in cases of jaundice from obstruction1 whether the seat of the obstruction be at the outlet or in the course of the duct4 ,,examination ,,of ,,the ,,renal ,,secretion4 ,the urine affords us important information in all cases of jaundice4 ,in fact1 an examination of it alone would in many cases enable us to discover the presence or absence of this affection4 ,diagnostic ,value of the ,colour of the ,urine4 ,the urine of jaundice has invariably a peculiar tint1 ranging from a saffron-yellow to a dark olive-green1 or almost black hue4 ,it must not be forgotten that the colour of normal urine varies with the degree of concentration4 ,where little is passed1 being of a high1 where much is passed1 of a pale colour2 the depth of colour depending on the degree of dilution of the urohmatine4 ,again1 it must also be remembered that there are many diseases1 which change the colour of urine very materially1 some only deepening1 others actually changing the tint4 ,foods1 and medicines also1 #ef alter the colour of the renal secretion4 ,rhubarb1 and santonine give to it a saffron hue1 arsenious acid gas a black colour4 ,bearing in mind these facts1 one would hesitate before giving a decided opinion as to the presence or absence of icterus from a mere inspection of the urine4 ,for this reason1 it is generally recommended in cases of jaundice to pour a little of the urine on a white plate1 and watch the play of colours produced by strong nitric acid4 ,this method1 however1 is not always satisfactory1 for the play of colours depends on the different stages of oxidation through which the pigment passes1 and other animal pigments1 besides biliverdine1 unfortunately act in a somewhat similar manner4 ,a very simple1 and more convenient way of testing the pigment without changing its physical characters1 is to separate it in combination with uric acid4 ,this is readily done by simply acidulating the urine with a few drops of hydrochloric acid1 and setting it aside for twenty-four hours to crystallize4 ,the white uric acid in crystallizing takes up the colouring matter1 and assumes the hue of the pigment present in the urine4 ,i have thus obtained crystals of all the different hues from a bright golden yellow tint through the intervening shades of red1 brown1 blue1 olive1 to a dark1 almost black colour4 ,this experiment #eg has another advantage1 for if we take a measured quantity of urine1 and collect1 dry1 and weigh the uric acid obtained from it1 we can readily calculate the total quantity passed in the twenty-four hours1 and thereby assist in diagnosing the presence or absence of malignant disease of the liver1 as ,i shall afterwards have occasion to point out4 ,the urine of jaundice is generally described as being of a saffron colour2 but if ,i may be allowed to form an opinion from my own observations1 which are tolerably numerous1 ,i should say that it1 in colour1 much more frequently resembles old ale than anything else with which ,i am acquainted4 ,on standing1 the colour changes very considerably1 in consequence of the pigment becoming slowly oxidized by its exposure to the air4 ,when there is a very great excess of bile pigment present in the blood1 the kidneys have some difficulty in eliminating it4 ,occasionally even1 it chokes up the renal capillaries1 and thereby complicates the jaundice by inducing secondary disease in the kidney4 ,in such cases the external surface of the kidney1 after the removal of the capsule1 looks as if it had been sprinkled over with ink4 ,the black specks vary in size from the minutest visible point to that of a pin-head4 ,the accompanying chromo-lithograph 7,plate ,,ii47 represents a kidney in this condition4 #eh ,it will also be observed that it is studded over with a number of small abscesses2 but whether these resulted from the blocking-up of the capillaries just alluded to or not1 it is impossible to say4 ,in the case in question no albumen was detected in the urine during life1 and it was only on careful analysis1 after the post-mortem had revealed the above state of matters1 that a small quantity was discovered2 and even then1 had not the experiment been carefully performed1 the presence of albumen might have been overlooked4 ,illustration3 ,plate ,,ii4 ,kidney from a ,case of ,permanent ,jaundice4 ,diagnostic ,value of the presence of the ,bile-,acids in the ,urine4 ,all acquainted with the recent literature of jaundice know how hard a battle is being fought between two sets of observers in ,germany1 regarding the presence of bile-acids in urine4 ,one class1 with ,frerichs and ,stdler at their head1 believe that the biliary acids are decomposed in the blood1 and are consequently never to be detected in the urine4 ,the other class1 headed by ,khne1 state as positively that they have detected these substances in the urine4 ,indeed1 ,khne states that by adopting ,hoppe's method1#ah he never fails to #ei detect the presence of the biliary acids in the urine of patients labouring under icterus1 as well as in the urine of dogs with the bile-duct ligatured4 ,when first studying this question1 ,i was very much perplexed by these contradictory statements1 for neither the judgment1 nor the power of observation of either of the authorities could for a moment be called in question2 and on experimenting for myself1 so unsatisfactory were the results obtained1 that ,i almost threw the question aside in despair4 ,on one occasion1 however1 ,i at length met with such unmistakeable evidence of the presence of bile-acids in the urine1 that ,i could no longer doubt the fact of their existence1 and was forced to search for an explanation of the previous contradictory results4 ,fortunately1 it was not very long before a solution to the difficulty was obtained1 and1 what was of still greater importance1 led to the observation that the contradictory results arose from a circumstance which might be turned to account1 as a means of differential diagnosis4 ,the discovery was1 that in certain cases of jaundice not a trace of the biliary acids is to be detected in the urine1 although the #fj bile pigment is present in abundance2 while in certain other cases both biliary acids1 and bile pigment occur in notable quantity4 ,what1 then1 is the cause of this difference8 ,simply this4 ,in jaundice from suppression the liver does not secrete bile2 consequently no bile-acids being formed1 none can enter the circulation1 and they are therefore not to be detected in the urine4 ,in jaundice from obstruction1 on the other hand1 bile is secreted1 and absorbed into the blood2 and the bile-acids not being all transformed in the circulation1 as ,frerichs supposed1 are eliminated by the kidneys1 and appear in the urine1 where they can be detected by ,hoppe's method1 or even1 with proper precautions1 by simply adding sulphuric acid and sugar4 ,here1 however1 some skill and experience are requisite1 in order not to confound the colour produced by the action of the reagents on other substances with the fine purple produced by the biliary acids4 ,as the majority of cases of jaundice result from suppression of the hepatic function1 and as many of the cases of obstruction ultimately merge into the former1 it is easily understood how the existence of the biliary acids in the urine has been so frequently denied4 ,i have myself seen1 in a case of obstruction of the common duct1 the biliary acids slowly and gradually diminished in the urine1 until they at length almost entirely #fa disappeared as the case approached a fatal termination4 ,here the disappearance of the biliary acids went on step for step with the impairment of the secreting powers of the liver1 in consequence of the pressure exercised on its parenchyma by the retained bile4 ,footnote #ah3 ,professor ,hoppe tests for bile-acids in the following manner3--,the urine is boiled with an excess of milk of lime for about half an hour1 and filtered to free it from the precipitate thus formed4 ,the filtrate is evaporated to dryness1 decomposed with hydrochloric acid1 washed with water1 and then extracted with alcohol4 ,the alcoholic extract contains the bile-acids1 which are recognised by ,pettenkofer's test4 ,the readiest mode by which the biliary acids may be detected is the following3 ,to a couple of drachms of the suspected urine add a small fragment of loaf-sugar1 and afterwards pour slowly into the test-tube about a drachm of strong sulphuric acid4 ,this should be done so as not to mix the two liquids4 ,if biliary acids be present1 there will be observed at the line of contact of the acid1 and urine--after standing for a few minutes--a deep purple hue4#ai ,this result may be taken as a sure indication that the jaundice is due to obstructed bile-ducts4 ,on the other hand1 the absence of this phenomenon1 and the occurrence of merely a brown instead of a purple tint1 although1 in the earlier stages of jaundice1 equally indicative of suppression1 is of course1 for the reasons already given1 no indication of the cause of the suppression4 ,that must be gleaned from other circumstances4 ,footnote #ai3 ,the immediate formation of a reddish coloured line is due to the acid setting free urohmatine1 the normal colouring matter of the urine4 ,it is seen that ,i have taken no notice of #fb ,frerichs' theory regarding the bile-acids being changed into bile pigment4 ,i have done so advisedly1 feeling as ,i do1 that when that observer investigates the subject more fully1 he will himself abandon such an untenable doctrine1 founded as it is1 on an erroneous view regarding the nature of bile pigment4 ,the colour induced by sulphuric acid on the acids of the bile1 is as different in its chemical nature from animal pigment1 as any two substances can possibly be4 ,indeed1 they have no bond of connection whatever1 except the mere tint4 ,all animal pigments1 whether they be green1 like bile-colouring matter1 or red1 like hmatine1 spring from the same source1 and contain iron4 ,besides this1 the mere fact of an increase of animal pigment being found in the urine after the bile-acids have been injected into the circulation1 to which ,frerichs attaches such importance1 in reality proves nothing more1 as ,khne pointed out1 than that an increased destruction of blood corpuscles has taken place4 ,i have found the urine of dogs loaded with dark colouring matter after injecting chloroform1 and other stimulants into their portal veins1 in order to establish artificial diabetes2 and1 assuredly1 in these cases the presence or absence of bile-acids in the blood had nothing to do with the result4 #fc ,diagnostic ,value of the presence of ,tyrosine1 and ,leucine in ,urine4 ,there are two other abnormal products occasionally met with in the urine of jaundice1 namely1 tyrosine1 and leucine4 ,these substances1 although for many years known to chemists1 attracted comparatively little attention until ,frerichs discovered their diagnostic value in hepatic disease4 ,illustration3 ,,fig4 #d4--;,crystals of pure tyrosine1 obtained from the urine of a case of chronic atrophy of the liver1 following upon obstruction of the bile-duct4 7a7 ,large crystals4 7b7 ,the more common form of the stellate groups of needle-shaped crystals4 7c7 ,a few separate fragments of needle-shaped crystals4 ,in that peculiar form of complaint1 described as acute or yellow atrophy of the liver1 the #fd urine is said invariably to contain tyrosine1 and leucine4 ,the presence of these substances may therefore assist us in diagnosing the case4 ,when tyrosine1 and leucine are present in quantity1 they are very readily detected1 all that is required being slowly to evaporate an ounce of urine1 to the consistency of syrup1 put it aside during a few hours to crystallize1 and then examine it with the microscope4 ,the tyrosine is recognised by being in fine stellate groups of needle-like crystals1 as represented in fig4 #d1 or spiculated balls not unlike a rolled-up hedgehog1 with the bristles sticking out in all directions4 ,illustration3 ,,fig4 #e4 ,spiculated balls of tyrosine1 from the urine of a case of acute atrophy of the liver4 ,when these were re-dissolved1 purified1 and re-crystallized1 they assumed the form represented in ,fig4 #d 7b74 #fe ,tyrosine may be obtained in a pure state by adding to four ounces of urine a solution of acetate of lead1 till a precipitate ceases to form1 filtering1 and freeing the liquid from the excess of lead by a current of sulphuretted hydrogen1 again filtering1 and evaporating the clear solution4 ,the tyrosine is now colourless1 and crystallizes with the microscopic characters above alluded to1 but still better marked4 ,tyrosine may be further recognised by putting a few crystals on a platinum spatula1 adding a drop or two of nitric acid1 and evaporating to dryness4 ,if present1 the yellow residue thus obtained assumes a pumpkin hue on the addition of potash1 and leaves on incineration a dark greasy stain4 ,frerichs recommends another test1 namely1 the following3--,put the suspected substance into a watch-glass1 along with some sulphuric acid1 and after they have been in contact about half an hour1 dilute the mixture with water4 ,next boil1 and then neutralize with carbonate of lime4 ,filter1 and to the clean filtrate add a few drops of perchloride of iron1 devoid of free acid4 ,the formation of a dark violet blue colour indicates the presence of tyrosine4 ,leucine is known by its flat1 circular1 oily-looking discs1 without any crystalline structure4 ,at the first glance1 a globule of leucine might be mistaken for oil1 not only on account of its #ff microscopical characters1 but also on account of its being lighter than water4 ,the globules of leucine are distinguished from those of oil by their being soluble in water1 and boiling alcohol1 and insoluble in ether4 ,besides this1 the discs are occasionally opaque and laminated like the granules of potato starch4 ,they are then not at all unlike microscopic crystals of the carbonate of lime2 but the carbonate of lime crystals sink in water4 ,illustration3 ,,fig4 #f4 ,dark globules of leucine of various sizes1 resembling in appearance globules of carbonate of lime4 ,both tyrosine1 and leucine are usually deeply impregnated with the colouring matter of the urine4 ,since ,frerichs' views were first published ,i have found tyrosine1 and leucine in the urine of cases of chronic1 as well as of acute atrophy of the liver4 ,their presence may therefore aid in diagnosing the latter as well as the former condition of the hepatic organ4 #fg ,i have little doubt that future research will discover other conditions of the liver1 besides those just mentioned1 in which tyrosine1 and leucine1 may appear in the urine2 for1 as will be subsequently pointed out at page #if1 ,i have been successful in producing them artificially in the urine of animals in which there was no evidence either of acute or chronic atrophy of the liver having taken place4 ,in the cases cited1 indeed1 it will be seen that the jaundice was the result of suppression1 consequent upon congestion of the liver1 produced by blood poisoning4 ,it may be added that since these observations were made ,i have found in the artificially concentrated urine of a case of jaundice from obstruction consequent upon impacted gall-stone1 a few balls closely resembling leucine in shape1 and size1 but differing from it in being excessively dark in colour4 ,no tyrosine crystals were observed1 and unfortunately there was not sufficient of the leucine-like substance present in the urine to admit of its being chemically tested4 ,i have thought it my duty to record this fact for the benefit of other observers1 as there can be little doubt that we are gradually verging towards some important discovery in a diagnostic point of view4 #fh ,melanine in the ,urine4 ,four years ago 7#aheh71 ,dr4 ,eiselt of ,prague called attention to the fact that in cases of melanotic cancer of the liver1 melanine appears in the renal secretion4#bj ,when the urine is passed it is usually quite clear2 but after standing it becomes of a dark colour1 even as dark as porter1 without1 however1 losing its transparency4 ,this deepening of the colour is no doubt due to the oxidation of the melanotic pigment1 as the employment of an oxidizing agent1 such as nitric or chromic acid1 causes the same change to occur instantly4 ,footnote #bj3 ,dr4 ,eiselt states that he also found melanine in the urine in a case of melanotic cancer of the eyeball4 ,in addition to the cases related by ,dr4 ,eiselt1 ,i am able to add one of considerable importance1 as it not only offers a striking illustration of the correctness of his views1 but has the double advantage of being an unbiassed record of facts1 in consequence of its having been observed1 and recorded long before ,dr4 ,eiselt's views were published1 and therefore at a time when the author had no idea of its significance4 ,the case occurred about thirteen years ago1 in the wards of the ,royal ,infirmary of ,edinburgh4 ,the history of the case ,i extract from my private note-book4 ,it is briefly as #fi follows3--,in the month of ,may a sailor was admitted into the clinical wards of the ,royal ,infirmary with symptoms of jaundice from enlarged liver4 ,he stated that he had been a great deal abroad1 in hot climates1 and admitted that he had been a hard drinker4 ,on admission his skin was of a dusky yellow colour1 and had been so since the month of ,february4 ,the liver was considerably enlarged1 and he complained of sudden violent pains in the neighbourhood of the umbilicus4 ,the pain was usually most severe during the night4 ,the urine was of a dark colour1 and on the addition of nitric acid1 became nearly quite black4 ,it contained no albumen4 ,the patient died ten days after admission4 ,on post-mortem examination1 the hepatic duct was found blocked up with malignant deposit1 and the liver of a dark green colour4 ,there was also a considerable amount of malignant deposit in the mesentery4 ,this patient1 as frequently happens in such cases1 became delirious before death4 ,in jaundice arising from melanotic cancer of the liver1 the recognition of the presence of melanine in the urine would be an important aid to the diagnosis4 ,care must be taken not to confound the dark olive-green urine occasionally met with in other forms of jaundice1 with the melanotic urine just described1 or both #gj patient and doctor may become unnecessarily alarmed4#ba ,footnote #ba3 ,while ,i was ,resident ,physician in the ,royal ,infirmary of ,edinburgh1 in #ahej1 a woman1 aged #bh1 was admitted with a universal and bright jaundice of three weeks' standing4 ,her urine was high coloured1 and of a specific gravity of #ajbb4 ,it contained a small quantity of albumen1 and became perfectly black on being boiled with nitric acid4 ,in this case there was no reason to suspect malignant disease of the liver2 the colour of the urine was1 therefore1 most probably due to the bile pigment being more than usually oxidized4 ,after a six weeks' stay in the hospital1 ,i dismissed the patient as cured4 ,urea1 ,uric ,acid1 and ,sugar4 ,the presence1 and quantity of certain other substances met with in the urine of jaundice1 although not peculiar to that condition1 nevertheless afford us important information1 not only as to its cause1 but also as to its probable mode of termination4 ,firstly1 a correct knowledge of the quantity of urea1 and of uric acid passed in the twenty-four hours is of great value2 and1 secondly1 the presence1 or absence of sugar is a fact which ought never to be lost sight of4 ,the value of this statement1 as well as of several of the preceding1 will1 ,i think1 be better appreciated by giving a short account of a case of obscure disease 7where a correct diagnosis1 and prognosis could not have been arrived at without the application of the chemical knowledge referred to71 than by any mere abstract #ga treatment of the question4 ,i shall1 therefore1 at once proceed to relate the brief history of the case4 ,a gentleman1 aged fifty1 who had been a remarkably healthy man1 observed1 within eighteen months of his death1 that his skin gradually assumed a more and more jaundiced tint without any assignable cause4 ,the stools were clay-coloured1 the urine loaded with bile pigment4 ,soon afterwards1 the patient began to lose flesh4 ,the liver became enlarged1 and somewhat tender to the touch2 the gall-bladder being at the same time so distended that it could be seen1 as well as felt1 projecting from under the false ribs4 ,as the case resisted the usual remedies1 the patient was recommended to try change of air4 ,during his absence from town1 he suddenly passed a large quantity of yellow matter by stool 7supposed to be bile71 and immediately afterwards the fulness in the abdomen disappeared4 ,on the patient's return to town1 the gall-bladder could no longer be seen or felt1 and it was naturally supposed that it had emptied itself on the occasion referred to4 ,as1 notwithstanding this1 the jaundice continued1 and the health and strength gradually declined1 ,dr4 ,prance1 under whose care the patient was1 sought the assistance of a physician of distinguished reputation in these affections4 ,at this period1 #gb however1 the entire absence of physical signs beyond the clay-coloured stools1 and those directly referrable to the jaundice1 rendered it impossible for any decided opinion to be arrived at4 ,the liver had now resumed its natural size1 and the only thing detectable was slight tenderness on pressure1 with a doubtful fulness in the pancreatic region4 ,these signs1 associated as they were with gradually increasing emaciation and debility1 led to the suspicion of malignant disease1 either in the course of the bile-ducts1 or at the head of the pancreas4 ,about this time it was discovered that the patient occasionally passed a considerable amount of a fatty-looking matter by stool--not mixed with the motion1 but separate1 though upon it4 ,after the passage of this matter1 there in general appeared to be a slight improvement in the patient's condition4 ,the substance in question1 on cooling1 solidified into a firm pale-brown matter1 resembling ,windsor soap1 and not at all unlike some of the biliary products4 ,this led to the idea that it might be composed of the fatty acids of the bile4 ,on one occasion a portion of it was forwarded to me for analysis1 and on subjecting it to chemical examination it proved to be1 strangely modified fish-oil1 the oleine of which had entirely disappeared4 ,in fact1 it was nothing but the sparingly soluble fatty acids of cod-liver oil1 which had #gc been transformed in the stomach1 and from which all the liquid principles had been absorbed4 ,this was considered an important discovery1 as it not only negatived the idea of the bile still reaching the intestines1 but also proved that the pancreas1 as well as the liver1 was affected4 ,having thus learned that the pancreatic juice1 as well as the bile1 failed to reach the intestines1 an effort was made to counteract the pernicious effect on the system caused by the absence of the former secretion1 by giving #a grains of pancreatine in the form of pill three times a day4 ,during the period that the patient was taking this medicine1 the quantity of fat passed by stool was supposed to diminish4 ,no decided improvement in the patient's condition took place1 however1 and on the #bnd of ,november the gentleman was brought to me by his medical attendant4 ,at this time the patient was much in the state already described1#bb and after a careful physical examination1 ,i failed to elicit any new fact of importance4 ,the hepatic dulness was perfectly natural2 there was no tenderness to speak of1 no history of gall-stones1 and #gd no evidence of any tumour beyond the doubtful fulness in the pancreatic region4 ,the digestive1 and other functions of the body1 except those already mentioned1 seemed unimpaired1 and yet the patient's strength daily declined4 ,as physical as well as symptomatical diagnosis proved inadequate to unravel the mystery of this obscure case1 and as chemical means had already1 in as far as it had been tried1 been of advantage1 it was resolved to subject the excretions to a rigid chemical examination4 ,the patient was accordingly desired to collect all the urine he passed during twenty-four hours1 and while ,i analysed it1 ,dr4 ,prance examined the stools1 in order to ascertain their composition--especially as regarded the amount of fatty and albuminous matters contained in them4 ,the urine yielded on analysis the following result3-- #bd ,,hours' ,,urine4 ,quantity 7#ee oz47 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 #agje c4c4 ,reaction 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 ,acid4 ,specific gravity 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 #ajah4 ,colour 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 ,greenish yellow4 ,urea 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 #bgbh grammes4 ,uric acid 7crystals large1 and of a dark-green colour7 #jeaa ,bile acids#bc 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 ,abundant4 #ge ,bile pigment#bd 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 ,abundant4 ,albumen 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 ,none4 ,sugar 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 ,none4 ,footnote #bb3 ,i noted his state to be as follows3--,skin of a black jaundiced tint 7dark green74 ,eyes deeply stained4 ,lips anmic4 ,considerable emaciation and debility4 ,extreme languor4 ,appetite good4 ,tongue1 and pulse not remarkable4 ,slight pain on pressure over the gall-bladder4 ,indistinct fulness in pancreatic region1 and to the left of middle line4 ,footnote #bc3 ,on the addition of sulphuric acid1 and white sugar to the urine1 a very marked1 and beautiful purple hue was obtained4 ,footnote #bd3 ,nitric acid at first turned the urine green1 but on the application of heat it became red1 and after prolonged boiling1 of a pale straw colour4 ,hydrochloric acid changed the colour of the urine immediately to a deep olive-green tint4 ,the facts here elicited were interpreted as follows3-- #ast1--,the quantity of urea which might be said to be normal1 was considered a favourable sign1 as it indicated that the stomachal digestion was unimpaired4 #bnd1--,the quantity of uric acid being below the average1 was likewise regarded as favourable1 tending as it did to negative the idea of cancerous disease of the liver2 the uric acid being in such cases usually increased4 #crdly1 and lastly1 the presence of the biliary acids1 as well as the bile pigment1 in the urine1 showed that bile was still being secreted1 but re-absorbed1 and this led at once to the diagnosis that the case was one of jaundice from obstruction4 ,here1 then1 was an important step gained4 ,the next point was1 if possible1 to ascertain the cause of the obstruction4 ,taking into account the absence of any tumour1 and any history of gall-stones1 together with the fact of the sudden disappearance of the enlarged gall-bladder1 my #gf first idea was that it might be a case of hydatids blocking up the common gall-duct1 and that on one occasion1 some large cyst had ruptured1 and discharged itself through the intestines4 ,on talking the case over with ,dr4 ,prance1 however1 that idea was abandoned1 and we were forced to content ourselves with the simple fact that the case was one of jaundice from obstruction of the common bile-duct1 complicated with occlusion of the pancreatic duct1 which fact had been previously ascertained by the discovery of the fatty acids in the fces4 ,about this time the patient took three grains of benzoic acid1 in the form of pill thrice a day1 and it was thought1 with the advantage of slightly diminishing the jaundiced state of the skin4 ,but no permanent benefit was obtained1 and after a time this remedial agent had to be discontinued1 in consequence of its having induced slight dyspepsia4 ,in the letter ,i received informing me of this fact1 it was also noted that there was much less both of the oily matter1 and albumen in the stools4 ,there was1 at the same time1 a considerable deposit of urates in the urine4 ,the specific gravity continued to be about #ajah4 ,the quantity in twenty-four hours about forty ounces4 ,on the #bith of ,november1 the patient was again brought to me1 and we made a careful examination of the size1 shape1 and exact position of the #gg hepatic organ4 ,the measurements were found to be #e inches at the extreme right1 #d inches at a line drawn perpendicularly to the nipple1 and #b inches midway between nipple and sternum4 ,beyond the centre of the sternum the liver did not reach4 ,as regards the size of the liver then1 there was still nothing very remarkable4 ,on this occasion it was observed1 that the patient's memory was not so good as formerly1 and that there was a certain amount of mental as well as bodily languor4 ,his hearing was likewise sluggish1 the words having occasionally to be repeated before they made an impression on the cerebral organ4 ,this1 no doubt1 arose from the poisonous effects of the bile circulating in his blood4 ,it may be here mentioned1 that in cases of jaundice from suppression we seldom or never meet with those extreme symptoms of cerebral disturbance which are so common in cases of jaundice from obstruction4 ,i believe the reason of this difference in the two forms of jaundice arises from the circumstance that the really poisonous parts of the bile are the biliary acids1 and that they1 like urea1 are powerful narcotic poisons4 ,the results of the experiments on artificial jaundice 7page #ie7 led me to this conclusion4 ,as neither the symptoms nor physical signs threw any additional light on this interesting case1 #gh it was determined once more to bring chemistry and the microscope to bear upon it1 with the view of1 if possible1 extending the information these methods of investigation had already yielded4 ,accordingly1 a specimen of the urine was again obtained for analysis1 and it yielded the following results3-- #bd ,,hours' ,,urine4 ,quantity1 7#dc oz47 4 4 4 4 #accc c4c4 ,specific gravity 4 4 4 4 4 #ajaf4 ,reaction 4 4 4 4 4 4 4 4 4 ,acid4 ,urea 4 4 4 4 4 4 4 4 4 4 4 #bciid grammes4 ,uric acid 4 4 4 4 4 4 4 4 #jbff ,bile pigment 4 4 4 4 4 4 4 ,abundant4 ,bile acids 4 4 4 4 4 4 4 4 ,small quantity4 ,sugar 4 4 4 4 4 4 4 4 4 4 ,a little4 ,solids 7total7 4 4 #daihi ,organic matter 4 4 4 4 4 4 #caiib ,inorganic 4 4 4 4 4 4 4 4 #iiig ,a marked change is here seen to have occurred in the constitution of the renal secretion4 ,first--the quantity of urea has notably diminished 7from #bgbh to #bcii grammes1 or in other words1 from #dbchd to #cgj grains47 ,the amount of uric acid has also fallen 7from #jeaa to #jbff grammes1 or in other words1 from #h to #d grains72 while at the same time the biliary acids have considerably decreased4 ,these changes are also seen to be accompanied by another1 which ,i at once regarded #gi as a most unfavourable sign1--namely1 the appearance of sugar in the urine4 ,although the quantity of sugar was as yet small1 and it was associated with a diminution in the bile acids1 it nevertheless made me look forward with gloomy forebodings1 for as far as my experience goes1 when the urine becomes saccharine in the course of a chronic1 and exhausting disease1 it has generally been the forerunner of a fatal termination4 ,this case1 ,i am sorry to say1 proved no exception to the rule4 ,there was1 indeed1 but one consolatory fact in the analysis1 and that was the diminution of the uric acid1 which1 as ,i before remarked1 tended to negative the idea of malignant disease of the liver1 and this was a great source of satisfaction to the patient4 ,eight days later1 #abth ,november1 a qualitative1 and quantative analysis of the urine was again made1 with the following result3-- #bd ,,hours' ,,urine4 ,quantity 7#cc oz47 4 4 4 4 4 4 4 #ajbc c4c4 ,reaction 4 4 4 4 4 4 4 4 4 4 4 ,acid4 ,specific gravity 4 4 4 4 4 4 4 #ajag4 ,urea 4 4 4 4 4 4 4 4 4 4 4 4 4 #aecde grammes4 ,uric acid 4 4 4 4 4 4 4 4 4 4 4 8 ,bile acids 4 4 4 4 4 4 4 4 4 4 ,none4 ,bile pigment 4 4 4 4 4 4 4 4 4 ,abundant4 ,sugar 4 4 4 4 4 4 4 4 4 4 4 4 4 ,increased4 #hj ,tyrosine1 and leucine#be 4 4 4 ,in small quantity4 ,solids 7total7 4 4 4 4 #bcdbf ,organic matter 4 4 4 4 4 4 4 4 #agfih ,inorganic 4 4 4 4 4 4 4 4 4 4 4 #egbh ,footnote #be3 ,on precipitating the urine with the acetate of lead1 filtering1 and freeing the clear liquid from the excess of that reagent by means of sulphuretted hydrogen1 and again filtering1 the liquid1 on evaporation1 was found to deposit small crystals of tyrosine1 and to have floating in it1 and on its surface1 round balls of leucine4 ,here1 is now to be observed1 the rapid downward progress of the case4 ,stomachal digestion1 as indicated by the amount of urea1 is much impaired4 ,the general health1 as indicated by the sugar1 is sadly affected1 and1 to crown all1 tyrosine1 and leucine1 the indicators of atrophy of the liver1 have made their appearance4 ,so unfavourable was the result of this analysis considered1 that ,dr4 ,prance felt himself bound to fulfil a promise he had made to the family some time previously1 of warning them of approaching danger1 when we had no longer any hope of the patient's recovery4 ,some time afterwards1 in the beginning of ,december1 we again saw the patient together1 and made a physical examination of the hepatic organ1 the result of which only confirmed our suspicions4 ,the liver was decidedly smaller4 ,the epigastric tenderness was increased4 ,the #ha jaundiced tint deeper4 ,petechial spots had now appeared on the trunk1 and arms4 ,the lower extremities were oedematous1 and the abdomen two-thirds filled with fluid4 ,on the #cast ,december1 ,i received a sample of urine1 and a note saying that the patient had slightly rallied4 ,but on examining the urine1 it was found to have a neutral reaction--it had previously always been acid--to be of a specific gravity of #ajai1 and on standing1 to deposit a copious sediment of lithates1 coloured intensely yellow with the bile pigment4 ,curiously enough1 the bile-acids had reappeared2 but only in quantity sufficient to admit of their being detected4 ,in spite of these trifling changes for the better1 the ominous one of an increased amount of sugar was still there4 ,a few days later1 and just before his death1 the patient had the benefit of another physician's opinion1 which1 although it differed somewhat from the foregoing1 was1 nevertheless1 equally unfavourable1 for he considered it a case of malignant disease4 ,the gentleman having noticed that his case excited considerable interest1 and some difference of opinion among his medical attendants1 directed that his body should be examined after death2 and as this wish was seconded by his wife1 #hb a lady of superior mind and accomplishments1 a post-mortem examination was accordingly made1 with the following results3-- ,firstly1--,the pancreatic duct1 as had been suspected1 was found completely occluded at its outlet1 and so distended by the accumulated secretion1 that it readily admitted the point of the little finger4 7,vide ,plate ,i41 g47 ,secondly1--,the orifice of the common bile-duct was in like manner completely obliterated1 and the duct itself immensely distended with dark thick tarry bile1 which on microscopic examination1 was found loaded with beautiful crystals of cholesterine4 7,fig4 #g47 ,illustration3 ,,fig4 #g4 ,the gall-bladder was enlarged to the size of a swan's egg1 and contained thick tarry fluid2 but no gall-stones1 or masses of inspissated bile4 ,the hepatic duct was greatly enlarged1 easily admitting #hc the point of the finger4 ,the cystic duct was also dilated1 though in a much less degree4 7,vide ,plate ,i41 c4 d4 e47 ,thirdly1--,the gall-bladder1 duodenum1 abdominal parietes1 and in fact all the abdominal viscera1 were intensely stained1 almost blackened1 by the osmosed bile4 ,fourthly1--,the bile1 on analysis1 was found to contain in one thousand parts3-- ,water 4 4 4 4 #fidde ,solids 4 4 4 #cjeee ------ #ajjjjj ,pigment 4 4 4 4 ,bile-acids 4 4 ,organic matter 4 #bhhii ,cholesterine 4 ,soda 4 4 4 4 4 ,potash 4 4 4 4 ,inorganic salts 4 #afef ,iron 4 4 4 4 4 ,whereas a specimen of normal bile taken from the gall-bladder of a woman aged sixty-one1 was of a specific gravity of #ajbj1 and contained in #ajjj parts3-- ,water 4 4 4 4 #iccbg ,solids 4 4 4 #ffgc ------ #ajjjjj #hd ,pigment 4 4 4 4 ,bile acids 4 4 ,organic matter 4 #efgc ,cholesterine 4 ,sugar 4 4 4 4 4 ,soda 4 4 4 4 4 ,potash 4 4 4 4 ,inorganic salts 4 #ajjj ,iron 4 4 4 4 4 ,the difference in composition of these two biles is very striking4 ,the one contains more than four times as much solid matter as the other2 and if the relative amount of organic1 and inorganic substances be compared1 the curious fact is observed1 that the difference in the amount of solids in the two cases1 is almost entirely due to the change in quantity of organic matter4 ,the inorganic salts have not even so much as doubled themselves in the abnormal bile4 ,whence is this8 ,soda is the chief inorganic substance found in bile1 and we have seen that it occurs in the form of glycocholate1 and taurocholate of soda1 substances which1 as before remarked1 are re-absorbed from the distended ducts1 and gall-bladder into the circulation1 from whence they are constantly being eliminated with the urine2 and this1 no doubt1 is one of the causes why the inorganic salts are proportionally in such small quantity in the abnormal bile of jaundice from obstruction4 #he ,fifthly1--,in the abdomen was a considerable quantity of dark straw-coloured serum1 which on the addition of strong sulphuric acid became of a fine emerald-green colour1 in consequence of the presence of bile4 ,traces of sugar were also present in the effused liquid4 ,the serum had only collected in the latter weeks of the patient's life1 and after the shrinking of the liver was observed to have begun4 ,sixthly1--,the liver was small in size1 excessively dense1 and very heavy4 ,externally1 it had a dark olive hue1 and on section presented a most curious appearance4 ,the section was of an almost uniform yellowish-green colour1 and studded over with excavations 7,plate ,i41 b71 from which thick bile streamed in all directions4 ,the apparent excavations were nothing more or less than immensely distended ducts4 ,on looking into the ducts1 it was observed that they presented the appearance of possessing valves4 ,on microscopical examination1 the hepatic cells were found smaller than normal1 as if partially atrophied4 ,the nuclei were unusually well marked1 in consequence of the fat granules being almost entirely absent4 7,fig4 #h1 b47 ,in the field of the microscope were a number of caudate or spindle-shaped cells 7,fig4 #h1 c471 from the epithelial lining of the ducts4 ,in the hepatic tissue were found some beautiful #hf stellate crystals1 as well as a number of separate needles of tyrosine4 ,a few small crystals of cystine were also found4 7,fig4 #h1 a47 ,illustration3 ,,fig4 #h4 ,seventhly1--,the kidneys were enlarged1 pale1 and fatty-looking2 and all over the surface of the section1 as well as immediately under the capsules1 which were very loosely attached1 were small abscesses4 ,the surface was also studded with numerous minute dark bile-pigment points1 and it is possible that the abscesses were the result of the blocking up of the capillary vessels by the pigment deposit1 as previously alluded to1 page #eg4 ,eighthly1--,the head of the pancreas was considerably enlarged1 and on cutting into it1 a quantity of pus oozed out from an abscess in its interior4 ,the abscess was found to communicate with a large ulcerated spot in the duodenum4 7,plate ,i41 f47 ,on microscopical examination1 the #hg tumour of the pancreas was found to consist of an hypertrophy of the normal gland tissue1 being1 in fact1 a chronic inflammatory tumour of the gland substance4 ,in no portion of the body was a trace of cancer detected1 nor any enlargement of the mesenteric or other glands1 to justify even a suspicion of malignant disease4 ,so the opinion arrived at regarding the pathology of this case is1 that the disease originated in an inflammatory affection of the pancreas1 during the progress of which1 the openings of the bile1 and pancreatic ducts became blocked up2 the interruption to the excretion of the bile giving rise to the jaundice1 and at the same time inducing engorgement1 and enlargement of the liver4 ,the inflammatory affection of the pancreas had probably ended in the formation of an abscess1 which1 pushing the enlarged liver forwards1 admitted of the distended gall-bladder being seen1 and felt through the abdominal parietes4 ,at length the abscess burst1 and suddenly emptied itself into the duodenum2 the yellow fluid discharged from the intestines being not bile1 as the patient had supposed1 but pus4 ,no sooner had the abscess emptied itself1 than the liver returned to its natural position1 and thus accounted for the distended gall-bladder so suddenly ceasing to be seen or felt4 ,the ulcer in the duodenum appears #hh to be the mouth of the abscess1 which has probably been prevented closing1 partly on account of the occasional draining away of pus1 which1 being in small quantity1 and mixed with the stools1 escaped detection2 and partly to the constant irritation of the passage of the food1 there being no bile or pancreatic fluid to neutralize the acidity of the chyme4 ,this might even be sufficient of itself to delay the healing process4 ,the ultimate gradual atrophy of the liver would arise from the continued pressure of the distended bile-ducts interrupting the hepatic circulation1 as formerly pointed out at page #dh4 ,lastly1 there being no bile or pancreatic juice admitted into the intestines1 the greater part of the food taken passed out of the body unabsorbed1 and the patient1 though possessing an excellent appetite1 and taking plenty of food1 actually died of slow starvation4 ,my object in giving such prominence to this interesting case1 is to show how valuable an adjunct physiological chemistry is to the other methods of diagnosis in obscure diseases of the abdominal organs1 and to encourage others to follow in the same path2 for it must be remembered that the foregoing was no dead-house diagnosis1 but that every fact here stated was discovered and recorded before death4 #hi ,having now explained the mechanism of the two forms of jaundice--that arising from suppression1 and that induced by obstruction--it only remains for me to remind my readers1 that there is frequently a combination of the two conditions4 ,jaundice from obstruction1 for example1 cannot long exist without becoming complicated with jaundice from suppression4 ,the continued backward pressure exerted on the hepatic parenchyma by the over-distended bile-tubes1 sooner or later impedes the circulation in the organ to an extent sufficient to induce an impairment1 if not an almost total arrest of the biliary secretion4 ,hence it is1 that in the last stage of jaundice from obstruction1 the biliary acids gradually diminish1 and at last finally disappear from the urine4 ,we have it1 nevertheless1 in our power to distinguish between the two forms of disease--for whereas1 in jaundice arising from simple suppression1 there is only an absence of the bile-acids2 in jaundice from obstruction1 complicated with suppression1 the absence of the bile-acids is usually associated with the presence of tyrosine1 and leucine4 ,for before complete suppression occurs as a result of obstruction1 the hepatic tissue has already had its nutrition so impaired1 as to admit of the formation of these foreign substances4 ,lastly1 the history of the case will of itself be an important guide4 #ij ,,epidemic ,,jaundice4 ,it is seldom that jaundice attacks persons in an epidemic form2 as it does so occasionally1 however1 and that too in almost all countries1 it is necessary that ,i should say a few words on its pathology4 ,in a quotation1 in the ,medical ,times and ,gazette1 from the ,recueil de ,mmoires de ,mdecine ,militaire1 vol4 iii4 p4 #cgd1 it is stated that1 ,m4 ,martin gave an account of an epidemic of jaundice which he had the opportunity of observing among the artillery and engineers of the ,french army stationed at ,pavia during the ,italian war4 ,it commenced during the great heats of ,august1 and terminated by the end of ,october4 ,there occurred #ga cases in an effective of #ajbb men4 ,the causes he considers to have been the unusual heat1 which gave rise to great congestion of the liver1 the fatigue of long marches 7the mounted men suffering oftener in proportion than the unmounted71 indulgence in alcoholic drinks1 and marsh miasmata4 ,great increase in the size of the liver in most of the cases1 and of the spleen in many1 was observed1 and all complained of pain in the epigastrium and in the hypochondria4 ,in fact1 this last was the first symptom of the approaching jaundice4 ,none of the cases proved fatal4 ,professor ,san-,galli #ia informed ,m4 ,martin that a similar epidemic prevailed in the town of ,pavia at the same time4 ,that jaundice may also occur in an epidemic form among pregnant women1 has been shown by ,dr4 ,saint-,vel1 who relates that1 ,in #aheh the island of ,martinique was1 without appreciable cause1 visited by an epidemic of jaundice1 remarkable for its severity in pregnant women4 ,it broke out at ,st4 ,pierre towards the middle of ,april1 attained its maximum height in ,june and ,july1 and terminated towards the end of the year4 ,all races were attacked2 the patients were mostly adults2 no liver-complication could be detected2 nor could any resemblance be traced between the disease and yellow fever4 ,it was fatal to females only1 especially during pregnancy4 ,of thirty pregnant women who were attacked at ,st4 ,pierre1 ten only arrived at the full period of pregnancy without presenting any other symptoms than those of ordinary jaundice4 ,the other twenty all had abortion or premature labour a fortnight or three weeks after the commencement of the attack1 and died in a state of coma1 which appeared a few hours before or after the expulsion of the foetus4 ,the females who died were from the fourth to the eighth month advanced in pregnancy4 ,in some cases1 slight delirium preceded the coma1 which was never interrupted1 but became more and more #ib profound up to the time of death4 ,its longest duration1 in two cases1 was twenty-four and thirty-six hours4 ,it was not preceded by any notable modification of the general sensibility1 nor of the respiration or circulation4 ,hmorrhage was absent1 except in one case1 where a female had it before delivery4 ,when death was delayed till three or four days after delivery1 the lochia were healthy4 ,almost all the children were still-born2 some lived a few hours2 one alone survived4 ,none of the infants had the icteric colour2 nor was there any sign of jaundice in the ten children born at the full term4 ,the foregoing translation from the ,gazette des ,hpitaux1 #bjth ,november #ahfb1 appeared in the ,british ,medical ,journal of the #gth of ,february1 #ahfc1 p4 #ada4 ,we have it further stated in the ,lancet of the #bast ,february #ahfc1 under the head of the ,health of ,rotherham1 that1 scarcely had the late fatal epidemic of fever subsided ere another1 less fatal1 but as widely spread1 took its place4 ,in last ,november several persons were attacked with jaundice1 and now not less than #aej persons are suffering from it4 ,none of those who were attacked by the late fever are suffering from the present epidemic4 ,when we reflect on the facts here related1 we #ic can have little difficulty in forming an opinion of the pathology of jaundice occurring in an epidemic form4 ,its mechanism seems to be precisely similar to that of the isolated cases of the disease which are every now and then met with as the result of blood-poisoning4 ,i have recently seen a case of well-marked jaundice supervene on an attack of scarlet fever1 and as it affords a tolerably good illustration of the pathology of such cases1 it may1 perhaps1 be briefly given with advantage4 ,a ,london cabman1 aged #bc1 was admitted under my care into ,university ,college ,hospital1 on the #bnd ,march of the present year4 ,he stated that he had always enjoyed good health1 but that lately he had been much out of spirits1 in consequence of the death of one of his relatives4 ,on the #beth ,february1 after three days' illness1 a scarlatinal rash appeared all over his chest1 and extremities1 and four days later 7the day before his admission71 he became jaundiced4 ,march #crd4 ,his skin is now of a bright yellow colour1 and when the finger is rapidly drawn across it1 a pink line immediately takes the place of the yellowness1 showing that there is still great subcutaneous vascularity4 ,the throat is sore1 and there is considerable difficulty in swallowing4 ,the conjunctiv are intensely yellow--proportionally more so than the skin1 in consequence of the scarlatinal hue being still #id blended with the tint of the latter4 ,the urine is high coloured1 has a slight deposit of urates2 contains a large amount of bile pigment1 but no bile-acids4 ,the stools have not been observed to be clay-coloured4 ,the liver is enlarged 7dulness extends #e inches in a perpendicular direction71 and tender on pressure4 ,he complains of pain in the hepatic region on taking a deep inspiration1 and of a general uneasiness at other times4 ,has no sickness or vomiting4 ,the mucous membrane of the tongue is red and raw-looking2 flakes of epithelial fur are readily detached from it4 ,the case was at once diagnosed as one of jaundice from suppression4 ,its mechanism being supposed to be identical to that of the cases discussed at pages #be-i under the head of jaundice arising from active congestion of the liver induced by blood-poisoning1 a dose of calomel and jalap was accordingly administered1 with the view of removing the portal congestion1 and with the most satisfactory result2 for1 notwithstanding the jaundice being complicated with scarlatina1 a very decided improvement in the colour of the skin took place within twenty-four hours1 the other symptoms remaining as before4 ,march #ajth4 ,the calomel and jalap was repeated on the #dth1 and since then the skin has gradually become paler4 ,it is now scarcely tinged4 #ie ,to return to the cases of epidemic jaundice2 they1 as ,i have just hinted1 are due to a precisely similar cause--blood-poisoning--either the direct result of miasmata1 or of contagion4 ,a further explanation of the reason why jaundice occurs in an epidemic form1 may be found in the circumstance that in all febrile states of the general system some one or other of the internal organs is liable to become congested4 ,for example1 typhus is1 as a rule1 complicated with cerebral congestion1 typhoid with mesenteric1 ague with splenic1 scarlatina with renal1 and so on4 ,it is not1 however1 necessary that the organs should be affected in the same relation to the disease as is here given4 ,on the contrary1 in one epidemic of typhus1 the brain may be congested1 in another the lungs1 and in a third the liver2 and so also with other fevers4 ,hence we can have little difficulty in understanding why epidemics of jaundice every now and then occur1 seeing that they are but the secondary results of other epidemic affections1 although1 as occasionally happens1 the jaundice is the chief1 if not the only well-marked symptom4 ,,artificial ,,jaundice4 ,what is the source of the tyrosine1 and leucine found in the urine1 in cases like those previously described8 ,being well aware that the physiologist #if has it in his power to produce almost any pathological state or artificial disease at pleasure1 ,i set about imitating on an animal the effects produced in the human subject by obstruction of the bile-ducts4 ,hitherto1 artificial jaundice has been usually induced either by ligaturing the gall-ducts or injecting bile into the circulation2 but as both of these methods were in the present instance objectionable--the first on account of the constitutional disturbance liable to be induced by the severity of the operation2 the second from the bile being all at once thrown into the circulation1 and thereby producing toxic effects1 besides the danger of its too rapid elimination by the urine--,i adopted another plan1 which came much nearer to the state induced by disease in man--,i took the bile of three healthy dogs1 and injected it under the skin of a fourth4 ,in this case the effects of the operation were almost nil1 and the bile was at the same time placed in a position favourable for its slow absorption1 just as in the human subject4 ,during the first two days the animal remained comparatively well1 the urine was normal in appearance1 and contained neither bile-pigment1 nor bile-acids4 ,but on the third day the animal became ill1 and on the fourth jaundice set in4 ,he died on the fifth4 ,after death the urine was found to contain not only #ig bile-pigment1 and bile-acids1 but also the diseased products1 leucine1 and tyrosine2 and what was more interesting still1 the urine was loaded with sugar1 just as occurred in the case imitated4 ,it will be remembered that in speaking of the bile-acids1 ,i mentioned that while glycocholic acid is a crystalline1 taurocholic is a non-crystalline substance4 ,tyrosine1 and leucine stand in a similar relation to each other2 tyrosine being crystallizable1 leucine non-crystallizable4 ,now1 taking this fact into account1 together with the fact1 that when the bile-acids are allowed slowly to enter the circulation1 they reappear in the urine1 accompanied with tyrosine1 and leucine2 and also with the third fact of these latter substances being found in the liver when the biliary function is interfered with1 ,i am inclined to look upon tyrosine1 and leucine as the products either of the arrested1 or of the retrograde metamorphosis of glycocholic1 and taurocholic acids4 ,moreover1 ,i have found in one case1 after injecting bile in the way before mentioned1 into the cellular tissue1 crystals of tyrosine spontaneously form in the bile taken from the animal's gall-bladder after death1 and merely allowed slowly to evaporate4 ,this result strengthens the foregoing opinion4 ,frerichs states that he has never detected the biliary acids in the blood1 even after bile had #ih been injected into the circulation4 ,in a remarkable case where #a oz4 of ox-bile killed a dog in less than five minutes from the time it began to be slowly injected into the jugular vein1 ,i detected the bile-acids in a clear extract of the blood1 with facility4 ,this leads me to mention that1 contrary to the statement of ,frerichs1 and in accordance with that of ,khne1 the injection of the pure bile-acids into the blood is very dangerous1 and that even the injection of pure bile into the cellular tissue1 often proves fatal in the course of twenty-four hours1 thereby showing that the constituents of the bile are highly poisonous4 ,in illustration of these facts ,i may cite the following experiments3-- ,into the cellular tissue of the back of a full-grown1 and healthy-looking terrier dog1 ,i injected the bile taken from the gall-bladders of three healthy dogs1 two of which had just been killed1 the other had been dead a few hours4 ,the bile was in the first two cases neutral1 in the third faintly alkaline4 ,all the biles seemed perfectly normal4 ,they contained no crystals of any kind4 ,eighteen hours after the operation the animal appeared quite well1 and took his food heartily4 ,four hours later a remarkable change took place4 ,the dog looked dull and drowsy1 and could not sustain himself on his legs2 when left to himself1 he #ii lay on his side1 and made not the slightest movement4 ,he was not only paralyzed1 but even the nerves of sensation had ceased to act1 for when his tail1 and feet were pinched1 he was quite insensible to pain4 ,the pupils were dilated1 and the body felt cold4 ,death occurred twenty-three hours after the operation4 ,urine1 and fces were passed in small quantity immediately before death4 ,the urine was strongly alkaline1 and effervesced on the addition of sulphuric acid1 thereby showing that it contained alkaline carbonates4 ,prismatic phosphatic crystals were present in the still fresh urine4 ,when tested for bile-acids1 only the faintest trace was obtained1 after the urine had been cleared with the acetate of lead and sulphuretted hydrogen4 ,the tissues of the abdomen and thorax were oedematous1 but1 within an hour after death1 had not the disagreeable odour found in animals killed by injecting pure bile-acid4 7,see foot-note at p4 #ci47 ,this experiment was again repeated with alkaline bile4 ,two ounces of ox-bile of a specific gravity of #ajbe were injected under the skin of a large pointer dog4 ,in twenty-four hours the animal was dead2 the sub-cutaneous tissue all round the seat of the injection1 red1 inflamed1 and infiltrated with #ajj blood4 ,the urinary bladder was empty4 ,the gall-bladder contained #a ounces of dark bile of a specific gravity of #ajdj4 ,when examined with the microscope1 the blood was found to contain a large excess of white corpuscles4#bf ,footnote #bf3 ,it has just been said that the blood contained a large amount of white blood corpuscles4 ,this reminds me of a fact that ,i have omitted to mention--namely1 that in a case of severe jaundice from suppression1 in consequence of cirrhosis of the liver1 ,i found that the blood possessed a very treacle-like aspect4 ,the serum was of a dingy yellow hue1 and felt somewhat sticky to the fingers4 ,under the microscope the blood corpuscles were found to be large1 and flabby1 had a great tendency to adhere together by the edges1 and become flattened on the sides whenever they came in contact4 ,moreover1 the corpuscles looked as if they had no distinct cell-wall2 some1 and that too1 in the freshly drawn blood1 gave off buds1 others split into two1 each half when separate looking like a distinct blood corpuscle4 ,in fact1 the blood looked more as if it had been acted upon by some powerful chemical agent than anything else4 ,i again examined it after the death of the patient1 and found it presented all the above characters in a still more marked degree4 ,to the naked eye it had a viscid1 tarry appearance4 ,these results rather militate against the theory of the bile being re-absorbed1 in an unchanged state1 into the circulation1 after the completion of the digestive process4 #aja ,,treatment ,,of ,,jaundice4 ,after what has been said regarding the pathology of jaundice1 ,i need scarcely remark that the treatment must vary according to the kind of disorder we have to deal with4 ,a line of treatment found to be beneficial in one case of jaundice1 might prove very hurtful in another4 ,for1 as has been shown in the foregoing pages1 jaundice from suppression1 and jaundice from obstruction1 are1 it might be said1 two entirely different diseases1 with only the symptoms of yellow skin1 high-coloured urine1 and pipe-clay stools in common4 ,the success of our treatment will therefore depend on our powers of diagnosis4 ,the general principles upon which the treatment of jaundice must be founded are as follows3-- ,the first and great object is1 of course1 as in the case of every other disease1 to remove1 if possible1 the exciting cause4 ,when that is accomplished1 we can with safety turn our attention to the removal of its effects4 ,i need not here detail the different exciting causes which it is our duty to remove4 ,i have indicated them elsewhere1 and the mere mention of some of their names is sufficient to denote the line of treatment which ought to be adopted4 ,thus1 for example1 if it be #ajb ascertained from there being symptoms of tenderness1 c41 in the hepatic region1 that the jaundice arises from active congestion of the liver1 the first object would of course be to subdue the congestion of that organ by means of leeches1 hot fomentations1 saline purgatives1 c41 according to the age1 sex1 and constitution of the patient4 ,on the other hand1 if the jaundice be the result of passive congestion of the liver1 we know well that so long as the exciting cause exists elsewhere1 it will be worse than futile to attempt the removal of the hepatic congestion by direct means4 ,in such a case1 therefore1 if to remedy the cause is beyond our power1 our object will be to concentrate our efforts on the mitigation of its effects4 ,thus ,i might go through the whole list of causes of jaundice1 and point out what appears to be the most appropriate treatment of each2 but ,i think the time of my readers and my space1 will be more profitably employed1 if1 instead of doing so1 ,i turn my remarks chiefly to the therapeutical action of those remedies which we are constantly employing in the treatment of jaundice4 ,the first remedy that merits special notice is mercury4 ,the benefit of mercury in cases of liver disease cannot be denied2 but the injudicious employment of this drug in cases of jaundice1 has frequently been followed by the most disastrous results4 #ajc ,there was a time when mercury was administered in all cases of jaundice1 irrespective of their cause2 now1 however1 men are fortunately becoming more careful in the employment of this drug4 ,but there is still a mistaken notion regarding the therapeutical action of mercurial preparations4 ,it was at one time thought that they stimulated the liver to secrete bile1 and now since physiology has shown that they possess no such action1 many have gone to the opposite extreme1 and declared1 that if mercurials do not stimulate the liver to secrete bile1 their benefit in hepatic disease has been a delusion2 and the dark stools following upon their employment but the result of the sulphuret of mercury formed in the intestines4 ,i take a very different view of the matter2 for though believing that mercury does not directly stimulate the liver to secrete bile1 ,i nevertheless opine that it has an important indirect effect in reinducing the biliary secretion1 and thereby curing certain cases of jaundice4 ,the action of mercurials seems to me1 to be this--mercury is a powerful antiphlogistic--it reduces the volume of the blood by its purgative properties1 and it impoverishes the blood by its direct action on the red corpuscles4 ,it has been poetically said by ,dr4 ,watson1 that mercury can blanch the rosy cheek to the white of the lily2 #ajd and nothing is more true1 for in experiments on animals1 ,i have found the prolonged use of mercury reduce the red blood corpuscles to a minimum4 ,from this it is easy to understand how mercury acts in inflammatory affections2 and as in the majority of cases of jaundice from suppression1 the stoppage of the biliary secretion is due to active congestion of the liver1 mercury proves beneficial in such cases1 not by stimulating the biliary secretion1 but simply by removing the obstacle to its re-establishment1 namely1 the hepatic congestion4 ,as a good illustration of the correctness of this theory regarding the action of mercurials in cases of jaundice arising from congestion1 ,i may be allowed to quote the following case1 which appeared among the ,hospital ,reports of the ,lancet of the #gth ,december1 #ahfa4 ,the case is headed1 ,intense ,congestion of the ,liver1 simulating an ,abdominal ,tumour3-- ,alex4 ,e----1 aged forty-eight1 was admitted into ,st4 ,bartholomew's ,hospital1 under the care of ,dr4 ,farre1 on the #agth ,october1 #ahfa4 ,the patient had1 it appeared1 been suffering from jaundice during six weeks4 ,he stated that the tumour in the epigastrium began about the same time as the yellowness of the skin4 ,on examination1 a prominent swelling was #aje noticed in the epigastric region1 possessing an indistinct feeling of fluctuation1 but it was found to be continuous with the liver4 ,the motions were not bilious1 but were of a clay colour1 and the urine looked like pure bile4 ,three grains of blue pill and two of ,barbadoes aloes were ordered every night4 ,by the #beth the hepatic tumour was less1 and the icterus was disappearing4 ,on ,november #dth the urine was clearer and full of lithates4 ,the conjunctiv were the only parts observed of a yellow colour4 ,november #aath4--,although the pills had been continued up to this date1 the mouth was not sore4 ,the urine and stools were natural1 and the patient was convalescent4 ,a few days afterwards he left the hospital4 ,the result of the case clearly proved not only that the swelling was from a highly congested liver1 but also that the jaundice depended on this state4 ,in this case it is evident that the primary beneficial action of the mercury was to reduce the congested state of the hepatic organ1 and no one1 ,i think1 would venture to say that this was accomplished by the power the mercury possessed of exciting the liver to secrete bile4 ,if1 then1 the above view of the therapeutical action of mercurials be correct1 it is easy to understand how1 in cases of jaundice from permanent #ajf obstruction of the gall-duct1 the administration of mercury or any other lowering medicine1 must prove detrimental by hastening the fatal termination4 ,although mercury has not1 there are some substances which have1 the power of exciting the flow of bile1 just as there are substances which excite the flow of saliva4 ,among these the mineral acids1 and soluble alkalies1 hold the first rank4 ,it may seem strange that acids1 and alkalies1 should be here placed in juxta-position2 but the reason of this arrangement will immediately appear4 ,according to a physiological law1 acid substances have the power of exciting alkaline secretions1 and alkaline substances of stimulating acid secretions4 ,bile being an alkaline secretion1 we can therefore have no difficulty in understanding how the mineral acids act in cases of jaundice from suppression1 induced1 for example1 by enervation4 ,they simply stimulate the secretion of bile4 ,it is not so easy1 however1 to comprehend the action of alkalies in similar cases4 ,my explanation of their action is as follows3--,when taken after food1 and when taken on an empty stomach1 the action of an alkali is entirely different4 ,after food1 and during digestion1 the stomach contains a #ajg quantity of acid gastric juice1 and an alkali taken then1 only neutralizes the acid4 ,on the other hand1 when an alkaline substance is introduced into an empty stomach1 it acts according to the general law of exciting an acid secretion2 consequently1 an immediate flow of gastric juice takes place4 ,and ,i believe it is the excess of this acid gastric juice1 which1 on reaching the duodenum1 stimulates the secretion1 and excites the flow from the gall-bladder of the alkaline bile1 just as the mineral acids do under similar circumstances4 ,one remark further is1 however1 necessary4 ,the quantity of alkali employed for the purpose of stimulating the secretion1 or of exciting the flow of the already secreted bile must be small1 for if much be used1 the greater part of the gastric juice will be rendered useless1 in consequence of its being neutralized as fast as it is secreted4 ,it may be laid down as a general rule1 that when we desire to increase the flow of bile by means of a mineral acid1 the acid must be given after food4 ,when1 on the other hand1 an alkali is selected for that purpose1 the alkali must be administered before food4 ,for obvious reasons1 both alkalies and acids are counter-indicated in cases of jaundice resulting from active congestion of the liver2 and it is equally evident that they can be of no direct #ajh service in jaundice arising from occlusion of the bile-duct1 where our object would be rather to diminish than to increase the secretion of bile4 ,alkalies1 or at least some alkalies1 possess certain other properties besides those to which allusion has just been made1 which may be usefully turned to account in the treatment of hepatic diseases4 ,for example1 we have been long told that alkaline carbonates are valuable remedies in cases of gall-stones1 in consequence of their possessing the power of dissolving biliary calculi4 ,now1 although ,i am not sufficiently enthusiastic to believe that alkalies can have much effect in dissolving gall-stones when once formed1 ,i nevertheless believe that they are of the utmost advantage in preventing and arresting their deposition4 ,the alkali to which ,i give preference is the carbonate of soda1 and the reason why ,i prefer it to the carbonate of potash1 is in consequence of my believing that the advantages derived from administering alkalies in cases of incipient gall-stones are entirely due to our being able thereby to increase the amount of glycocholate1 and taurocholate of soda present in the bile2 both of which substances1 separately or combined1 retain cholesterine in a soluble form2 and1 as is well known1 by far the greater number of biliary calculi are composed almost entirely of pure cholesterine4 #aji ,the carbonate of soda has yet another advantage4 ,it was long ago observed by ,dr4 ,prout that gall-stones are very common in persons of a gouty1 and rheumatic tendency of body1 a fact which ,i have myself been able to confirm on several occasions1 by making a quantitative analysis of the uric acid in the twenty-four hours' urine1 as recommended at page #ef4 ,in such cases the carbonated alkali is of double service1 for while increasing the solvent in the bile1 it at the same time counteracts the uric acid diathesis4 ,in a case of gall-stones1 in a woman aged #cf1 where there was an almost daily deposit of fine crystalline uric acid in the urine1 it was found necessary to continue the administration of ten grains of soda1 with five of rhubarb1 three times a-day during two months1 before this tendency to lithic acid deposit was entirely overcome4 ,recently ,i have prescribed lithia water to persons of the uric acid diathesis in whom ,i had reason to suspect the existence of a predisposition to gall-stones2 and when it was necessary to combine it with stimulants1 sherry has been the wine selected4 ,for some further remarks on the treatment of gall-stones1 see pages #aad1 #aai1 and #abc4 ,there is a remedy to which ,i wish to call special attention1 namely1 benzoic acid4 ,this substance was first recommended as a remedy in #aaj jaundice by a ,german physician1 about six years ago4 ,since then1 ,i have tried it several times1 and found it of benefit in jaundice arising from suppression4 ,in those cases of obstruction1 on the other hand1 in which ,i tried it1 it appeared to be anything but beneficial4 ,i give it in the form of pill1 three times a day4 ,dr4 ,green1 one of my former pupils1 who has just returned from ,india1 tells me that he acted on my suggestion1 and tried it in a case of well-marked jaundice1 following an attack of delirium tremens2 and that by the end of eight days it would have required an experienced eye to detect the tinging of the conjunctiv4 ,the following may be cited as a tolerably good example of the value of benzoic acid in cases of jaundice from enervation3-- ,william ,m----1 aged eleven years1 labouring under an acute attack of severe jaundice1 came under my care at ,university ,college ,hospital on the #bnd of ,february4 ,the patient appeared to be a moderately developed1 and very intelligent boy4 ,the jaundiced condition of the skin1 his mother said1 was first noticed on the #cjth of ,january1 only two days before he came to the hospital4 ,it was further ascertained that1 although the boy had for some length of time been subject to monthly attacks of severe headache1 and bilious vomiting1 he had never before suffered from #aaa jaundice4 ,on the present occasion he complained of headache1 but it was unaccompanied either by sickness or vomiting4 ,on examination the liver was found normal in size1 and not in the least tender on pressure4 ,the bowels were moderately open1 and the stools not clay-coloured4 ,the urine was of a deep orange tint1 and the skin of a dark yellow hue4 ,there was an abundance of bile pigment1 but not a trace of bile-acids in the urine4 ,as the jaundice appeared to be the result of enervation1 brought on by over mental exertion1 the boy was ordered to be kept from school1 and not allowed to read any books 7his mother said he was always reading74 ,at the same time three grains of benzoic acid were ordered to be taken thrice a-day4 #ith ,february4--,the skin was now very much paler1 the yellow colour being nearly gone4 ,the conjunctiv were still yellow1 although less so than at last visit4 ,the urine remained unchanged in colour4 ,he was ordered to continue the medicine4 #afth ,february4--,skin perfectly normal in colour2 if anything perhaps a shade whiter than natural4 ,conjunctiv no longer yellow4 ,dismissed cured4 ,in this case no medicine whatever1 except the benzoic acid1 was given4 ,as far as my experience goes1 benzoic acid #aab appears to be most useful in jaundice arising from enervation or from active congestion1 as in the case related at page #bg2 but in cases of the latter kind it seems to be of little service until the acute symptoms have disappeared4 ,i am still rather doubtful regarding the mode in which it acts1 although one point seems clear1 namely1 that it hastens the re-absorption from the tissues1 and elimination from the body1 of the bile-pigment4 ,it thus appears to play the part of a whitewash2 for1 as one of my lady patients once graphically said1 the medicine had bleached her4 ,on one occasion ,i tried benzoic acid in a case of jaundice following upon an attack of ague2 but it proved of no service4 ,indeed1 quinine1 combined with mercurials1 seemed in that case to be the only remedy4 ,there is another drug which proves of service in jaundice from suppression1 namely1 podophyllin1 or ,may-apple4 ,this remedy1 which was first introduced from ,america1 is supposed to possess both the alterative and purgative properties of mercury4 ,as an alterative1 it is given in doses varying from #a_/h to of a grain1 three times a-day2 as a purgative1 from to #a grain1 as a single dose4 ,i have given this remedy a tolerably fair trial1 and although it seems to be very useful as a purgative in hepatic disease1 and to increase the flow of bile1 ,i have found it open to two objections3 #aac firstly1 its action is slow1 and not always certain2 and1 secondly1 in delicate females it gives rise to a good deal of griping4 ,this latter objection can1 however1 to a certain extent1 be counteracted1 by combining the remedy with hyoscyamus4 ,on the whole1 ,i prefer mercurials to podophyllin1 and only administer the latter in slight cases of jaundice1 or in those where mercurials are counter-indicated4 ,for example1 in cases of feeble liver1 where there is an insufficient secretion of bile from want of nervous power1 podophyllin is decidedly of service1 for in such cases mercury is of course counter-indicated4 ,moreover1 podophyllin can be advantageously combined with vegetable tonics1 and1 when given along with gentian or quinine1 forms an admirable hepatic stimulant in some of the cases usually denominated torpid liver4 ,i cannot refrain from making a few remarks on what ,i consider the injudicious employment of podophyllin4 ,like every new remedy1 it has to run the risk of falling into disfavour1 in consequence of its too ardent admirers blindly prescribing it in all cases of hepatic disease2 in many of which it must of necessity prove unsuitable1 if not even detrimental4 ,in cases of jaundice1 for example1 podophyllin is at one1 and the same time1 the bane1 and the antidote4 ,the bane in all cases of #aad jaundice from obstruction1 the antidote in a few cases of jaundice from suppression4 ,having already indicated the cases in which it may be administered with advantage1 ,i shall now call attention to one of those where it cannot be employed without injury1 and one in which it is1 nevertheless1 frequently given4 ,the case ,i allude to is that of gall-stones4 ,when once a gall-stone has formed1 and is blocking up the common bile-duct1 thereby causing jaundice from obstruction1 it is easy enough to understand why a substance like podophyllin1 which increases the biliary secretion1 is to be avoided4 ,it is not1 however1 so easy to understand why the remedy is equally counter-indicated1 either during the formation or sojourn of a gall-stone in the gall-bladder4 ,this1 therefore1 ,i must explain4 ,in speaking of the mode of formation of gall-stones in the gall-bladder 7page #dc71 ,i have stated that their formation is due to the deposition of the less soluble parts of the bile1 either as a consequence of these ingredients being in excess1 or in consequence of the solvent1 whose duty it is to retain them in solution1 being in reduced quantity4 ,it follows1 then1 as a natural result1 that the longer bile sojourns in the gall-bladder1 and the thicker it becomes1 the more likely are its constituents to be deposited1 and increase the size of the already existing concretion1 #aae or give origin to a new formation4 ,it may be further added1 that the greater the amount of bile secreted1 the longer is it likely to remain in the gall-bladder1 and the more concentrated to become2 for1 as is well known1 there is a constant absorption of the aqueous particles of the bile going on during the whole time it is stored up in its reservoir4 ,if1 then1 during the intervals of digestion1 the liver secretes merely sufficient bile to meet the requirements of the succeeding meal1 by the end of the digestive process the gall-bladder will be entirely emptied of its contents1 and ready to receive a fresh supply4 ,whereas1 if the liver secretes more bile during the intervals of digestion than the wants of the system require2 after the completion of each succeeding meal the excess of bile will remain behind in the gall-bladder1 and1 while becoming stored up with that subsequently secreted1 of necessity1 favour the increase or excite the formation of gall-stones in persons predisposed to them4 ,there being nothing more conducive to the deposition of biliary calculi than a well-filled gall-bladder4 ,as a warning against the indiscriminate use of podophyllin1 ,i may cite the following case1 which has come under my notice as these sheets are passing through the press4 ,a few weeks ago ,i received a telegram requesting me to visit1 as #aaf early as possible1 a lady dwelling in the neighbourhood of ,st4 ,john's ,wood4 ,on my arrival ,i found the lady suffering from a well-marked jaundice1 and considerably prostrated in consequence of her having just arrived from ,brighton1 where she had gone for the benefit of her health1 but where1 instead of getting better1 she got considerably worse4 ,the history of the case was1 that the lady had been seized with pain in the back 7middle of dorsal region7 about three weeks before ,i saw her4 ,that there had been great tenderness in the region of the gall-bladder--so much so1 that she could scarcely tolerate the pressure of her stays2 and that she had suffered from occasional attacks of sickness after eating4 ,on examining the patient ,i found the liver enlarged1 and tender on pressure4 ,the gall-bladder much distended1 and easily felt4 ,the skin of a yellow hue4 ,the stools of a pale tint4 ,the urine very dark-coloured1 and loaded with lithates4 ,i had1 consequently1 no difficulty in diagnosing the case as one of gall-stone impacted in the common bile-duct2 but on communicating my suspicions to the patient1 ,i was informed that such could not possibly be the case1 for during a considerable time past she had been carefully treated with podophyllin4 ,indeed1 ,i learned to my surprise that she had taken from a quarter to #aag half a grain of that substance nearly every day during the six previous months6 ,this incidental piece of information1 instead of shaking my opinion1 as the patient had apparently expected1 only tended to strengthen my suspicions1 for the reasons previously given1 namely1 that the podophyllin must have tended to keep the gall-bladder constantly full of bile4 ,i accordingly prescribed for the case as one of impacted gall-stone1 and left instructions that the stools should be carefully examined for its appearance4 ,on the following day the patient felt better2 but the jaundiced tint was deeper1 the stools paler1 and the urine still high-coloured4 ,the deposit of lithates had1 however1 slightly diminished4 ,still1 feeling certain that the case was one of impacted gall-stone1 ,i ordered the medicine to be repeated1 and the stools to be again carefully examined4#bg ,on my arrival at the patient's house the next day1 the maid met me with an expression of satisfaction which could not be misinterpreted1 and ,i had scarcely entered the sick chamber when1 with an #aah air of triumph1 she showed me a gall-stone about the size of a large garden-pea1 or small field-bean4 ,it had been passed that morning about #aa o'clock1 that is to say about fifteen hours after the second dose of medicine4 ,on analysis the stone was found to consist almost entirely of cholesterine1 and ,i have not the smallest doubt in my own mind that to the constant use of the podophyllin may1 in a great measure1 be attributed its formation4 ,unfortunately the stone had been accidentally broken before ,i saw it1 and ,i was consequently unable to ascertain decidedly whether it was a solitary calculus1 or one of many4 ,had it been one of several1 it would of course have possessed facets4 ,one facet would have indicated that the stone was one of two2 two facets that three stones existed2 three facets1 that the gall-bladder had contained at least four calculi2 while four or more facets would denote that the stone was one of many2 whereas1 if it was a solitary calculus1 no such markings would be present4 ,footnote #bg3 ,we are sometimes told to add water to the stools1 and that if gall-stones are present they will be found floating on the surface4 ,i have never yet been able to detect a gall-stone in this way4 ,the plan ,i recommend is1 therefore1 to mix the stool freely with water1 and either decant the supernatant fluid1 and then add fresh portions of water till the whole of the soluble matter is removed1 or to strain the mixture through a hair-sieve4 ,the gall-stone in either case remains behind1 and can be readily detected4 ,i may merely add1 in conclusion1 that from the time the stone passed1 the stools resumed their normal colour--the first two or three were much darker than natural1 in consequence of the sudden escape of the pent-up bile--the urine gradually became pale1 and clear1 and the skin regained its wonted hue4 ,the latter change was expedited by #aai the administration of benzoic acid1 and in a week from my first visit1 a stranger would have been quite unable to detect that the patient had laboured under a recent attack of jaundice4 ,a few years ago a mixture of sulphuric ether1 and turpentine was very extensively used1 especially in ,france1 as a solvent for gall-stones4 ,this line of treatment was adopted on account of the well-known solubility of cholesterine in sulphuric ether1 and it was thought that the remedy would act upon the cholesterine concretions in the gall-bladder in the same manner as it did out of the body4 ,after a time1 faith in the powers of the mixture became shaken1 and it at length gradually ceased to be employed4 ,within the last year or two1 ,dr4 ,bouchut#bh has revived the same theory with another form of remedy1 namely1 chloroform1 which he administers internally1 with the view of dissolving any inspissated bile or biliary calculi that may be lodging in the gall-bladder4 ,dr4 ,bouchut states that he has treated one case of gall-stones in this manner with success4 ,now1 although ,i have not the slightest desire to throw discredit on the statement of ,dr4 ,bouchut1 ,i must candidly admit that ,i am very much inclined to doubt the accuracy of his observations4 ,in the first place1 it is always #abj extremely difficult to ascertain the existence of biliary concretions so long as they remain in the gall-bladder1 and it is equally difficult to know1 after gall-stones have been once passed by a patient1 whether or not all have come away4 ,if1 then1 we administer chloroform to a patient1 either before or after a gall-stone has actually passed1 we cannot1 with anything approaching to certainty1 attribute the cessation of his symptoms to the circumstance of the chloroform having dissolved a gall-stone4 ,in fact1 on physiological grounds1 ,i very much doubt the efficacy of either sulphuric ether or chloroform as solvents of gall-stones in the living body4 ,sulphuric ether1 and chloroform would no doubt dissolve a concretion of cholesterine in the gall-bladder were they admitted into that viscus in sufficient quantity1 and in a pure state4 ,but we have no proof that such is the case4 ,on the contrary1 we know1 at least in as far as chloroform is concerned1 that exactly the opposite is the fact2 for no sooner does chloroform become absorbed1 and mingled with the constituents of the blood1 than it becomes decomposed1 the chlorine combining with the blood1 and the formic acid being set free4#bi ,and even supposing that sulphuric ether and chloroform existed in the blood in a free state1 they could not possibly do so in a sufficiently #aba concentrated form to be able to act as solvents of biliary calculi4 ,footnote #bh3 ,edin4 ,med4 ,journ4 #ahfa1 p4 #cih4 ,footnote #bi3 ,jackson1 ,comptes ,rendus1 ,february #beth1 #ahef4 ,my own experiments on animals have shown me how rapidly fatal even small quantities of chloroform are when injected into the circulation1 and a similar remark is equally applicable to sulphuric ether4 ,a few drops of these substances can very readily be injected into the circulation with impunity2#cj but the quantity must not be increased beyond a certain amount1 far less than could possibly dissolve a single grain of cholesterine1 otherwise immediate death follows the operation1 by inducing a state of body closely resembling rigor mortis1 from which the animals never recover4 ,i am1 therefore1 completely at a loss to understand how these remedies can be of service in dissolving gall-stones in the living body2 and as ,i make it a rule as seldom as possible to prescribe a remedy without a knowledge of its physiological action1 ,i have not yet ventured on an empirical trial of the effects of sulphuric ether or chloroform administered internally in cases of gall-stones4 ,for some remarks on the passage of biliary calculi1 see page #abc4 ,footnote #cj3 ,vide the ,author's paper on a new method of producing diabetes artificially in animals1 by the injection of stimulants--alcohol1 ether1 chloroform1 ammonia1 c4--into the portal circulation4 ,comptes ,rendus de la ,societ de ,biologie de ,paris4 #ahec4 #abb ,taraxacum has been widely used in hepatic disease associated with jaundice1 and is believed to be particularly well adapted to cases arising from congestion4 ,as in such cases ,i generally trust to more potent drugs1 my experience with this remedy has been too limited to admit of my offering an opinion of its value4 ,the majority of cases of jaundice from obstruction1 are much less under the power of remedial agents than those arising from suppression1 for we have here three distinct conditions to combat3 ,firstly1--,the derangements originating in the absence of bile from the digestive canal4 ,secondly1--,the morbid effects arising from its accumulation in the ducts1 and consequent interruption to the hepatic functions4 ,thirdly1--,the general poisonous action on the system1 of the re-absorbed bile4 ,as regards the first of these effects1--namely1 the derangements arising from an absence of bile from the digestive canal1 it may be said that if these were the only difficulties with which we had to contend in cases of jaundice from obstruction1 they could easily be overcome4 ,for1 in the first place1 the absence of bile is not attended with any immediate danger1 a circumstance which has led to the common belief that the presence of bile is not absolutely essential to life4 ,experiments on dogs #abc with biliary fistul1 like those before referred to1 as well as cases in the human subject1 have proved that life may be sustained1 under certain conditions1 for a very long period1 without bile reaching the intestines4 ,indeed1 the only immediate bad effects which appear to result from its absence1 are costive bowels1 great flatulence1 and extremely offensive stools4 ,the indirect bad results1--namely1 loss of flesh1 c41 as has been proved by experiments on animals1 can be counteracted by giving an additional amount of food2 and even the direct results of constipation1 flatulence1 and foetor1 may be overcome by appropriate remedies4 ,the secondary morbid effects1 namely1 those arising from the accumulation of bile in the ducts1 are unfortunately not so easily under control4 ,could we remove the cause of obstruction1 these would1 of course1 immediately cease4 ,this1 however1 is seldom in our power1 except in the case of gall-stones1 the expulsion of which we can aid in various ways4 ,in general1 we can very successfully aid the passage of a stone through the ducts by administering an anodyne containing a full dose of the tincture of belladonna1 which apparently assists in dilating the duct4 ,placing the patient in a warm bath is also of service2 and when the paroxysms of pain are very severe1 the occasional inhalation of the vapor from a couple #abd of drachms of sulphuric ether poured on a handkerchief1 made into the form of a cup1 is generally attended with great relief4 ,each of these modes of treatment may be followed either by a brisk emetic1 or purgative1 in the hope that the efforts of vomiting or purging may hasten the expulsion of the stone1 either by the mouth or rectum4 ,it ought never to be forgotten1 that the evil results of a gall-stone do not always cease when it has reached the intestinal canal4 ,even death itself has resulted from the impaction of a gall-stone in the duodenum4 ,when we have any suspicion that the stone is large1 our treatment must therefore be continued until its extrusion by the mouth or rectum has been accomplished4 ,when the occlusion of the common bile-duct is caused by an organic tumour1 no treatment of ours can be expected to remove the obstacle1 and sooner or later the patient is carried to an untimely grave4 ,our efforts of relief in such a case ought therefore to be directed to another channel2 and here1 in order to give the sufferer at least some chance of recovery1 even although it be little better than a forlorn hope1 ,i cannot refrain from recommending1 in cases of permanent occlusion of the duct1 in which there is great distension of the gall-bladder1 the establishment of an artificial biliary fistula4 ,were this done1 the patient would be placed1 as #abe nearly as possible1 in the same condition as an animal in which the operation has been performed for physiological purposes1 and1 we might almost hope1 with an equally favourable result1 at least1 in as far as the biliary functions are concerned4 ,in the first place1 we would have removed all the derangements resulting from the interruption to the flow of bile1 and consequent upon the distension of the ducts4 ,in the second place1 we would have obviated the danger arising from the poisonous effects of the re-absorbed bile1 which the experiments previously cited 7page #ih7 show are of no trifling nature2 and1 lastly1 we would only require to combat the evils arising from the absence of the biliary secretion in the digestive process1 which1 as was before said1 can to a certain extent be overcome by giving an additional quantity of food1 and paying attention to the bowels4 ,in these remarks ,i have omitted taking into consideration the effects that might arise from the tumour1 or other obstructing cause to the biliary secretion1 for these would in no way be directly influenced by the establishment of the biliary fistula4 ,the artificial establishment of a biliary fistula in the human subject1 is not such an ,utopian idea as might at first be imagined4 ,distended gall-bladders having been several times tapped with #abf success1 both in this and other countries1 and the permanent establishment of a fistula1 if done in the manner ,i shall immediately point out1 would1 in my opinion1 be a much less hazardous operation than simple tapping4 ,biliary fistula in dogs are generally made in a single operation1 by cutting through the abdominal parietes1 seizing the gall-bladder1 stitching it to the lips of the wound1 and inserting a cannula4 ,here there is always some danger of the wound not healing by the first intention1 and of the passage of bile into the abdominal cavity4 ,in the case of the human subject1 ,i should1 therefore1 recommend the inducing of the adhesion of the gall-bladder to the abdominal parietes by means of an escharotic1 before making the opening2 in which case1 ,i can scarcely imagine that the operation would prove one either of difficulty or danger4 ,but even supposing that it were not entirely free from either1 it would still surely be preferable to give the patient at least a chance of prolonging his life1 rather than to permit a fatal affection to run its uninterrupted course1 which we know can1 at best1 be calculated by months only4 ,in those cases of jaundice from obstruction1 where it might be considered inadvisable to adopt the plan here suggested1 we ought in our treatment carefully to avoid the common error of #abg administering mercury1 or other substances supposed to have the power of augmenting the biliary secretion4 ,we must equally avoid the administration of foods likely to produce a similar effect1 for the sufferings of the patient are not so much due to a deficient secretion1 as to a want of biliary excretion4 ,our whole energies should be directed to sustaining the strength of the patient1 and mitigating1 if possible1 the physical effects of the accumulation of the bile in the gall-bladder and biliary ducts1 as well as the poisonous action of the re-absorbed secretion4 ,this1 ,i believe1 we can best do by administering light and readily digested food1 keeping the bowels open by gentle purgatives1 and favouring the elimination of the biliary constituents from the blood by mild diuretics4 ,our object may be still further advanced by artificially supplying the place of the absent bile in the digestive process4 ,not1 however1 in the way usually adopted1 of giving inspissated bile along with the food2 a method of treatment which originated ere modern physiology rent the veil of therapeutical empiricism4 ,in the first place1 the bile prepared according to the method indicated in the pharmacopoeias1 has its most essential properties destroyed during the process of preparation4 ,and in the second place1 we have hitherto been instructed to administer it #abh at the very time which modern research has proved to be the most unsuitable that could possibly be devised4 ,in administering bile immediately after food1 as is usually done1 we most effectually produce the contrary result to what is intended4 ,when bile mingles with gastric juice1 it destroys the digestive power of the latter1 so that by giving the bile immediately or soon after a meal1 we really diminish instead of increase the digestive functions4 ,my experiments1 both chemical1 and physiological1 have led me to propose not only a new method of preparing bile for medicinal purposes1 but also to suggest an entirely new mode of administering it4 ,firstly1--,as regards the method of preparation4 ,nothing can be more simple1 and at the same time more effectual4 ,fresh bile1 taken directly from the gall-bladder of the newly killed pig1 is filtered1 through very porous filter-paper1 to free it from mucus2 it is then as rapidly as possible evaporated to dryness at a temperature not exceeding #afj ,fahr4 ,the bile1 as soon as dried1 is ready for use4 ,simple as this operation appears in theory1 there are two practical difficulties connected with it--#ast1 ,bile filters very slowly1 and consequently little must be put into the filter at a time4 #bnd1 ,bile is rather hygroscopic1 and consequently1 in order to get it dried quickly1 it is necessary #abi to spread it over a large surface4 ,if the bile has been well prepared1 that is to say1 thoroughly freed by filtration from its ferment mucus1 and well dried1 it will keep in stoppered bottles for many months without losing any of its active properties4 ,having stated that bile as at present employed more frequently does harm than good1 by retarding instead of hastening the digestive process1 ,i have now to point out the manner in which it may be given with advantage4 ,if bile be administered1 as ,i propose1 at the end of stomachal digestion1 it will1 as in the healthy organism1 act on the chyme at the proper moment1 and thereby render it fit for absorption4 ,in order still further to ensure the action of the bile being delayed until the food is in a condition favourable to its action1 that is to say1 until it is ready to pass from the stomach into the duodenum1 ,i have had the bile1 as above prepared1 put into capsules1#ca which are not readily acted on by the gastric juice4 ,while in the stomach1 the capsules1 however1 swell up from the size of a pea to that of a small gooseberry1 and at the same time become so soft that they will readily burst in passing the pylorus into the duodenum1 and thereby allow #acj the bile to escape1 and come in contact with the food at the precise moment its action becomes requisite in the digestive process4#cb ,the capsules not only preserve the active properties of the bile for an almost indefinite period1 but they have the advantage of most effectually preventing the patient tasting the remedy4 ,footnote #ca3 ,the capsules were made by ,savory and ,moore1 and ,i have every reason to be satisfied with the manner in which they accomplished the object in view4 ,footnote #cb3 ,prepared bile1 made up into an ordinary pill1 dissolves in gastric juice in a quarter of an hour4 ,when the pill is silvered it is dissolved in half an hour1 and when gilded1 in forty minutes4 ,whereas1 in the same specimen of gastric juice1 the capsules prepared for me by ,savory and ,moore1 although swollen to more than three times their original size1 were nevertheless intact at the end of an hour and a half4 ,they readily broke on being gently squeezed between the finger and thumb1 it is not therefore probable that they would pass the pylorus in this condition without giving way1 and allowing their contents to escape4 ,each capsule contains five grains of the prepared bile2 and five grains is equal to one hundred grains of liquid bile fresh from the gall-bladder4 ,two capsules therefore represent two hundred grains of pure bile1 a quantity 7though less1 perhaps1 than the healthy organism consumes during each digestion7 which in most cases would be sufficient for the wants of the system4 ,if1 however1 a larger amount be considered necessary1 there is no reason why three or more capsules should not be given4 ,by the administration of prepared bile in the manner here described1 the physician is enabled to imitate nature1 and #aca supply an important element to the system2 which1 although incapable of curing the disease1 can nevertheless ward off for a time the fatal termination4#cc ,footnote #cc3 ,it is not alone in cases of jaundice that the prepared bile may be of service1 but also in the various forms of duodenal dyspepsia1 so common among the literary classes1 consequent upon either a deficient quantity1 or an abnormal quality of bile4 #acb ,,tabular ,,view ,,of ,,the ,,pathology ,,of ,,jaundice1 ,,according ,,to ,,the ,,author',s ,,views4 ,from ,enervation4 4 4 4 4 4 ,fright4 ,suppression4 ,anxiety4 ,over-mental exertion4 ,concussion of ,brain4 ,congestion ,active4 4 ,hepatitis4 of ,liver4 ,direct ,violence4 ,dyspepsia4 ,ague4 ,typhus4 ,typhoid4 ,scarlatina4 ,pymia4 ,yellow ,fever4 ,poison4 ,jaundice4 ,passive4 ,heart ,disease4 ,pneumonia4 ,pleurisy4 ,imperfect ,circulation in the ,newborn4 ,absence of ,secreting ,cancer4 ,substance4 ,cirrhosis4 ,fatty ,degeneration4 ,amyloid ,degeneration4 ,atrophy4 ,acute4 ,chronic4 ,from ,congenital ,deficiency ,small ,ducts 787 ,obstruction4 of ,ducts4 ,common ,duct4 ,accidental ,obstruction,gall-stones4 in course of ,duct4 ,hydatids4 ,foreign ,bodies from ,intestines4 ,closure of ,outlet4 4 ,pressure of ,pregnant ,uterus4 ,impacted ,fces in ,transverse ,colon4 ,organic ,disease of ,pancreas1 or of neighbouring ,organs4 ,abscess in ,head of ,pancreas4 ,ulcer of ,duodenum4 #acc ,,index4 ,a4 ,abscess in kidney1 #eh in pancreas1 #hf ,acids1 treatment by1 #ajf of bile1 #h1 #cf1 #eh ,acute atrophy of liver1 #cd ,ague1 jaundice in1 #bh urine in1 #bh ,albumen in urine of ague1 #bh ,albuminose1 #ad ,alkalies1 treatment by1 #ajf ,artificial jaundice1 #ie ,atrophy of liver1 #cd ,b4 ,benzoic acid1 treatment by1 #aji ,bidder's researches1 #af ,bile1 acids of1 #h1 #cf1 #eh tests for1 #eh1 #fa action of1 on albumen1 #ad action on fats1 #af analysis of1 #hc colour of1 #aj diseased1 #hc drunk by ,caffres1 #ai effects of food on1 #aa inorganic constituents1 of1 #aj pigment in kidneys1 #eg1 #hf mode of secretion1 #aa nature of1 #g1 #hc in digestive process1 #ae essential to life8 #ac specific gravity of1 #aj treatment of jaundice by1 #abg resin1 #aj ,biliary fistula1 #abd ,biliverdine1 #g1 #ef ,blood in jaundice1 #ajj ,budd's 7,dr471 views1 #g1 #cj ,c4 ,cancer of liver1 #cb of pancreas1 #df ,carbonate of soda1 treatment by1 #ajh ,cherry-stones in bile-ducts1 #de ,cholesterine1 #h1 #hb1 #ajh ,colour of bile1 #aj ,congestion1 hepatic1 #bd1 #ajd ,cystine1 #hf ,d4 ,diseases with which jaundice is associated1 #c ,dyspepsia1 #bf ,e4 ,eiselt 7,dr471 #fh ,enervation1 #bb1 #aaj ,epidemic jaundice1 #ij ,f4 ,farre 7,dr471 case1 #ajd ,fat in fces1 #ed1 #gb absorption of1 #af ,flatulence1 #ac ,frerichs on mechanism of jaundice1 #f1 #cc ,fright1 effect of1 #bc ,g4 ,gall-bladder1 absence of in animals1 #ab1 #da congenital deficiency of1 #dj ,gall-stones-- mode of escape from gall-bladder1 #dd mode of formation1 #dc in common duct1 #dd in gall-bladder1 #dc in intestines1 #abc treatment of1 #ajh1 #aad1 #aai1 #abc carbonate of soda in1 #ajh chloroform in1 #aai podophyllin in1 #aae sulphuric ether in1 #aai ,glycocholic acid1 #h1 #ig ,glycocholate of soda1 #h injected into blood1 #ci ,h4 ,heart disease1 jaundice in1 #cj ,hepatic congestion1 #bd1 #ajd ,hoppe's method1 #eh ,hydatids in bile-ducts1 #de ,i4 ,impacted fces1 effect of1 #df ,inflammation of liver1 #bd1 #ajd ,inorganic constituents of bile1 #aj1 #hc ,intestinal excretion1 analysis of1 #ea ,introduction1 #a ,j4 ,jaundice1 artificial1 #ie from acute atrophy of the liver1 #cd absence of bile-duct1 #dj absence of gall-bladder1 #da absence of secreting substance1 #ca ague1 #bg blood-poisoning1 #bg1 #ic blow on head1 #bd cancer1 #cb enervation1 #bb1 #aaj entozoa1 #de epidemic1 #ij from fright1 #bc gall-stones1 #db1 #aaf hepatic congestion1 #bd1 #ajd mental emotion1 #bb1 #aaj active hepatic congestion1 #be1 #ajd passive hepatic congestion1 #bi disease of the pancreas1 #df pregnancy1 #df obstruction1 #ci1 #ga scarlatina1 #ic suppression1 #bj typhus1 #bg tubercle1 #cb zymotic disease1 #bg1 #ij mechanism of1 #ai treatment of1 #aja ,k4 ,kidneys as eliminating organs1 #aa ,khne's views1 #eh1 #ih ,l4 ,lenz's experiments1 #af ,leucine1 #fc1 #hj1 #ie ,liver cells1 #ch1 #he ,liver1 extirpation of1 #aa ,m4 ,marcet 7,dr471 #af ,martin 7,dr471 #ij ,matteucci 7,prof471 #ag ,melanine in urine1 #fh ,mercurials1 treatment by1 #ajb ,milk in jaundice1 #bb ,o4 ,obstruction1 of bile-duct1 #ga of pancreatic duct1 #ga treatment in jaundice from1 #abb ,p4 ,pancreas1 abscess in1 #hg ,pancreatine1 #gc ,pancreatic juice1 #ah absence of1 #gc ,pathology of jaundice1 tabular view of1 #acb ,pathological conditions with which jaundice is associated1 #c1 #acb ,pettenkofer's test1 #cf ,pipe-clay stools1 #eb ,pneumonia1 jaundice in1 #cj ,podophyllin1 treatment by1 #aab in cases of gall-stones1 #aad ,prance 7,dr471 #ga ,pregnancy1 jaundice in1 #ia ,pregnant uterus1 effect of1 #df ,prepared bile1 treatment by1 #abg ,s4 ,saint-,vel 7,dr471 #ia ,scarlatina associated with jaundice1 #ic ,schmidt's researches1 #af ,specific gravity of bile1 #aj1 #hc ,sputa in jaundice1 #bb ,stools1 fat in1 #ed1 #gb colour of1 #eb ,sugar1 a normal constituent of bile1 #aj in urine1 #gj ,sulphuric ether1 #aai ,suppression1 jaundice from1 #bj ,sweat in jaundice1 #bb ,t4 ,table of the pathology of jaundice1 #acb ,taurocholate of soda1 #h ,taurocholic acid1 #h1 #ig ,tears in jaundice1 #bb ,theories regarding mechanism of jaundice1 #e ,treatment of jaundice1 #aja by acids1 #ajf by alkalies1 #ajf by benzoic acid1 #aji by biliary fistula1 #abd by carbonate of soda1 #ajh of gall-stones1 #ajh1 #aad1 #aai1 #abc by ,lithia water1 #aji by mercurials1 #ajb of jaundice from obstruction1 #abb by podophyllin1 #aab by prepared bile1 #abg by taraxacum1 #abb ,tubercle1 #cb ,tyrosine1 #fc1 #hj1 #ie ,u4 ,urea1 #gj ,uric acid1 #ef1 #gj ,urine1 analysis of1 #ee in acute atrophy1 #cf in jaundice from ague1 #bh in obstruction of bile-duct1 #gd1 #gh1 #gi bile-acids in1 #cf1 #eh1 #gd1 #ig colour of1 #ee tyrosine and leucine in1 #cf1 #hj1 #ie melanine in the1 #fh uric acid1 #ef1 #gj sugar in1 #gj ,urohmatine1 #g1 #ee ,w4 ,wilks's cases1 #ce1 #dj ,y4 ,yellow atrophy of liver1 #cd ,,william ,,stevens1 ,,printer1 #cg1 ,,bell ,,yard1 ,,temple ,,bar4