jaundice from suppressed secretion, as well as in that which results from closure of the gall-ducts; but in inflammation of the gall-ducts the tenderness is probably less diffused, and felt more exclusively in the situation of the common duct, which is open to pressure.

One of the surest signs of the existence of this kind of jaundice would be diminution in the size of the liver, if it could be satisfactorily made out; but it is much more difficult to estimate diminution of the liver than enlargement. When the liver grows large, it extends below the false ribs and across the epigastrium, and can generally be felt through the yielding walls of the belly; but when the liver shrinks from its natural size, its lower edge rises under the ribs, and changes in the bulk of the organ are difficult to detect. It is probable that the surest means of distinguishing this kind of jaundice will, by and by, be found in some peculiar condition of the urine. I have long suspected that the presence of oxalate of lime in the urine will turn out to be an important indication of it. In many cases of jaundice which I have supposed to be of this kind, the urine contained oxalate of lime, which disappeared from it as the jaundice went off. In more than one case of the kind, I have found in the urine, with the oxalate of lime, casts of the secreting tubules, or evidence of the rapid shedding of the epithelium of the secreting tubules, of the kidney. But none of these cases have proved fatal, so that the real nature of the jaundice is in some degree doubtful.

1

Until more is known of the causes of this form of disease, and until it can be detected with more certainty, we cannot expect to have satisfactory proof of the good or ill effects of particular plans of treatment.

A consideration of the foregoing cases leads, however, to the important and gratifying inference that in two or three of them the terrible head-symptoms were prevented, or removed, and the life of the patient was saved, by active purging. If this inference be true, there can be little doubt that purgatives will generally be productive of benefit in milder cases of the same kind.

The medicine which has seemed to be the most generally useful in cases of jaundice, which I have supposed to result from suppressed secretion, is from 3ss to 3j of sulphate of magnesia, in conjunction with gr. xv of carb. of magnesia, and 3ss of aromatic spirits of ammonia, three times a day-the sulphate of magnesia to keep up

free action of the bowels; the carbonate of magnesia to neutralize any excess of acid in the stomach or bowels; and the aromatic spirit of ammonia to support the nervous system, and to keep up the action of the skin.

SECT. II.-Fatty Degeneration of the Liver-Partial deposit of Fat in the Liver-Wary Liver-Appearances caused by deficiency of Fat in the Liver.

IT has been before remarked that the size, and color, and firmness of the liver may become much altered, without the agency of inflammation, and without destruction of the cells or impaired nutrition of its other tissues-simply from matter being secreted or appropriated by the cells, which, instead of passing off freely in the bile, is retained in the substance of the liver.

The most common disease of this class is what has been called the fatty liver, or fatty degeneration of the liver.

The outward characters of this disease have been long familiar to pathologists, and have been rightly ascribed to the interstitial deposit of uncombined fatty matter in the substance of the liver; but it was not known precisely in what state, or where, the fat was deposited till 1841,' when Mr. Bowman discovered, in a specimen of very fatty liver which I requested him to examine with this intent, that it existed in the form of oil-globules in the hepatic cells.

In every human liver there is some uncombined oil or fat, which, in healthy, grown-up persons, amounts, perhaps, on an average, to three or four per cent. of the whole mass.

In the spring of 1851, Mr. L. S. Beale was kind enough to make, at my request, an analysis of two livers presumed to be healthy. The first was that of a gentleman, 31 years of age, well formed and muscular, and above the middle stature, who had led a temperate life, and who, while in perfect health, was killed by falling from a secondfloor window; the second was that of a schoolmistress, 40 years of age, who had lived well, but very temperately, and had enjoyed

1 See Lancet, Jan. 22, 1842.

good health, until an attack of cerebral hemorrhage, of which she died.

The following are the results of the analysis :

Von Bibra, who has made an elaborate examination of the liver fats, has published the analysis of two livers presumed to be healthy: the first taken from a healthy young man, killed suddenly by a blow; the second, taken from an itinerant, the nature of whose illness was unknown. The quantity of fatty matter they contained in 100 parts was 2.50, and 3.65, respectively.

The fatty matter of the liver, when separated by alcohol and ether, has always a brown color, and, according to Von Bibra, contains from one and a half to three per cent. of phosphorus. It consists chiefly of olein, which dissolves the more solid fatty principles, so that it all has the form of globules of oil. In consequence of this, its presence is most readily detected by the microscope, through which it may be seen in the hepatic cells in the form of very small globules, having a dark outline. These globules are of various sizes, and are placed irregularly in the cells. Their usual appearance is represented in Fig. 6 (p. 27).

In the fatty liver the quantity of fatty matter is enormously increased. The hepatic cells are gorged with large globules, which greatly distend them, and often obscure their nuclei. This is represented in Fig. 8 (p. 29).

Usually a great number of oil-globules of various sizes, not contained in cells, are likewise seen under the microscope.

The figures denoting fatty matter in these analyses were obtained by evaporatirg a portion of the liver over a water-bath, then treating the dry powdered residue with successive portions of boiling ether, until nothing further was extracted, and, finally, weighing the matter left on evaporation of the ether.

The quantity of oil thus accumulated in a liver may equal in weight, and more than equal in bulk, all the other elements of the liver put together. M. Vauquelin obtained from a portion of fatty liver, by boiling, as much as 45 parts of oil in 100 of liver. Nearly half the liver, in weight, consisted of uncombined oil.

A liver, still more remarkable for the large amount of fat it contained, fell under my observation in King's College Hospital, in the spring of 1850. It was taken from a drunkard, and was in a state of cirrhosis, as well as of fatty degeneration, and, in consequence, presented a very remarkable "hob-nailed" appearance, from the nodules of cirrhosis being enlarged by the accumulation of oil. A portion of it blazed when thrown into the fire, and a particle from the lobular substance had, under the microscope, almost the appearance of ordinary fatty tissue, from the number and size of the oilglobules it contained. Mr. L. S. Beale made an analysis of a portion of it for me, and found that 65 parts in 100-about six-sevenths of all the solid matter in the liver-consisted of fat.' The following are the particulars of the analysis :

The fatty matter consisted of saponifiable fats, the greater part of which was oily fat. The man had ascites and slight jaundice, but

1 The result of this analysis is so extraordinary that I subjoin, in Mr. Beale's words, a statement of the method employed in making it :

"A portion of the liver was evaporated to dryness, and then treated with a mixture of alcohol and ether. The solution thus obtained was evaporated to dryness, and the dry matter, which consisted of fat, with a little extractive matter and salts, was weighed. The residue, insoluble in alcohol and ether, was dried and weighed. It was attempted to separate the extractive matter and salts from the fat, by treating the mass with water, but, in consequence of the large quantity of fat, this proceeding was found not practicable. After the fats had remained for two or three days on the surface of water, they separated into two portions: the lighter, yellow, oily, and perfectly fluid at the ordinary temperature: the heavier, white, granular, opaque, and crystalline; the crystals forming dense, radiating, striated, globular masses.”

was reported to have died without medical attendance, after two days' illness. A coroner's inquest was in consequence held, and the body was carefully examined by the physician's assistant at the hospital. No tubercles existed in the lungs, and no organ was found notably diseased except the liver. The kidneys appeared to be healthy.

A liver that has undergone the fatty degeneration is larger, paler, softer, and more greasy than natural. These changes in its sensible qualities depend chiefly, if not solely, on the interstitial deposit of the oil-globules, and their degree may give us some estimate of the quantity of oil the liver contains. When this is very large, the liver is large in proportion, sometimes twice its natural size, and is somewhat altered in shape, being thicker than natural, and having its edges blunter or more rounded. The capsule of the liver is stretched and smooth, and when divided its edges recede. The tissue of the liver is pale, and, generally, throughout of a soft buff color, dotted with brown or red. The brown or red dots mark the centres of the lobules, which are unusually large and distinct, and are buff-colored near their margins. The liver is very soft, and greases the hands, or the scalpel, like common fat.

When the quantity of oil is less, the liver is not so large nor so soft, and is less uniformly pale. It sometimes happens, as was, I believe, first observed by Mr. Gulliver, that the cells near the margins of the lobules contain a very much larger quantity of oil than those near the centres; and, as the blood almost always collects after death in the central parts of the lobules especially, there is a striking contrast between the pale buff-colored margins of the lobules, and the red or brownish central portions; and a section of the liver presents the appearance described as the nutmeg-liver. The liver may not feel greasy, but an unusual quantity of fat may be at once detected by placing a thin slice of the liver on a piece of paper, and exposing it to the action of heat. Some of the oil or fat exudes, and greases the paper. The best way, however, of ascertaining the quantity of fatty matter is by examining a small particle of the lobular substance of the liver through the microscope. The oilglobules are objects of sight, and from their form and their dark outline are at once distinguished.

When the fatty degeneration occurs in a liver previously healthy, the different parts of the organ are commonly affected in pretty equal