sumed the characters of ileus, and all the usual means were employed with little relief.-16th. There was some discharge from the bowels after a tobacco injection, but it was very scanty. Severe pain continued, with every expression of intense suffering. Her strength sunk, and she died on the morning of the 17th.

Inspection.-Every part of the intestinal canal was perfectly healthy, except the upper part of the duodenum, where there was considerable appearance of inflammation, with remarkable softening, so that it was very easily torn. A large irregular calculus was found sticking in the ductus communis, and the parts were so softened that it came through the side of the duct when it was very slightly handled. In the texture behind the duodenum there was considerable appearance of inflammation. No morbid appearance could be detected in any other organ.

II. Perforation or rupture of the gall bladder, or one of its ducts, and escape of the bile into the peritoneal cavity. The immediate effect of this accident is rapid peritonitis, fatal in eighteen or twenty-four hours. The symptoms preceding it will depend upon its cause, and consequently may be either very obscure, or such as indicate great distention of the gall bladder, with obstruction of the bile in its passage out of it. The causes of the affection are chiefly referable to two classes.

(1.) Obstruction of the common duct. This may take place rapidly by adhesive inflammation, or more slowly by gradual obliteration. In the former case the symptoms are rapid, as in a man mentioned by Andral, who had acute pain, followed by jaundice, and a pyriform swelling rising up from under the margin of the ribs. On the fifth day he was suddenly attacked with peritonitis, and died in twenty

four hours. The ductus communis was found much contracted, and at one place obliterated. The gall bladder and the hepatic and cystic ducts bore marks of having been much distended; the rupture had taken place in the hepatic duct, and much bile was found in the peritoneal cavity. In another, the symptoms of obstruction to the passage of the bile had been going on for between two and three months before the fatal attack, and in this case both the cystic and common ducts were found much contracted.

(2.) Perforation of the coats of the gall bladder by ulceration. A man mentioned in the Nouveau Journal de Medicine for 1821, had been affected for more than a month with pain in the abdomen and fever, which had various remissions and aggravations. On the 37th day of the disease, he was suddenly seized with symptoms of the most violent peritonitis, and died on the following morning after suffering inexpressible agony. On inspection, there were found marks of most extensive peritonitis. The inner surface of the gall bladder presented numerous small circular ulcers from one to three lines in diameter; two of them had entirely perforated its coats, so as to allow the escape of the bile into the peritoneal cavity.

SECTION IV.

CHANGES IN THE QUALITY AND QUANTITY OF THE BILE.

THE chronic diseases of the liver seem to impair the functions of digestion, partly by the actual pressure upon the stomach, when the liver is enlarged or hardened; and

partly by morbid changes in the secretion of the bile from that condition which we know to be necessary to healthy digestion. There is a good deal of hypothesis, on this subject; but there are certain points, in regard to the changes of the bile, which we may consider as ascertained with some degree of precision.

1. We can have little doubt that the bile is often deficient in quantity, producing dyspeptic symptoms, with paleness of the stools. This seems to arise chiefly in connection with the pale degeneration of the liver, especially when the organ is much diminished in size; but in some of the extraordinary masses of disease which have been described, showing almost every point of the liver altered from the healthy structure, there were no symptoms indicating that the bile was either deficient or vitiated,-the motions being healthy, and the digestion little impaired, until a very short time before death. This occurred in a very remarkable manner in Case CXLIII.

2. The bile appears to be sometimes much altered in quality. The only means by which we can judge of this with any degree of precision, is from the appearance of the bile which is found in the gall bladder. In some diseases of the liver, accordingly, we find there a fluid of an albuminous or watery appearance, without any of the sensible qualities of bile. When we observe a change so very remarkable as this, we may conclude that other changes may take place in the quality of the bile, less cognizable to our senses, though they may impair in a great degree the functions of digestion; but this subject is at present involved in much obscurity.

3. It is probable that the bile may be increased in quantity; but it must at the same time be admitted, that

our prevailing notions on the subject are rather hypothetical than founded upon facts. The bile is a viscid fluid of a green colour, and, when it is mixed with the usual contents of the intestinal canal, it imparts to them a bright yellow. When the motions became of a dull white or ash colour, we judge with tolerable precision of the deficiency of bile; but I am not aware of any test by which we can judge with precision of its redundancy; and I must confess my suspicion, that the term bilious stools is often applied, in a very vague manner, to evacuations which merely consist of thin feculent matter mixed with mucus from the intestinal membrane. On this subject I find a late intelligent writer on the diseases of India, expressing himself in the following manner, after alluding to the doctrine of several systematic writers in regard to bilious diarrhoea, arising from increased secretion of bile: "not a single fact is produced by either of these authors in support of their opinion, and it seems to rest merely upon the popular notion that the colour of the feces is derived from the bile; but this doctrine seems rather to be taken for granted than proved."*

SECTION V.

PATHOLOGY OF JAUNDICE.

JAUNDICE is produced by the absorption of bile into the circulation, and this is generally connected with some ob

• Mr. Tytler,—Calcutta Transactions, vol. iii.

struction to its passage from the liver into the duodenum. It must be confessed, however, that there is much obscurity in the pathology of many cases of jaundice, and that some of the causes which have been assigned for it are in a great measure hypothetical. Among these perhaps may be reckoned morbid viscidity of the bile, spasm of the ducts, overflow of bile, and what has been termed bilious congestion. These and some others of the same kind must be perhaps considered rather as hypotheses framed to correspond with the facts, than as deductions from them, and therefore not entitled to much confidence.

When, with a view to practical utility, we consider the circumstances under which chiefly jaundice takes place, they seem to be referable to the following heads.

I. The passage of a gall stone. Jaundice takes place from this cause, when the calculus is a considerable time in passing, so as to produce an obstruction of some continuance in the duct; when it passes in a shorter time, though the symptoms may be equally severe, no jaundice follows. The precise period which is necessary for the production of jaundice has not been ascertained; it is probable that it varies in different cases.

This form of the disease is in general distinguished by the violence of the pain, but cases have occurred in which the disease was distinctly referred to this cause, while the symptoms had been severe vomiting and jaundice, with very little pain. This occurred in a woman, mentioned in the fifth volume of the medical repository, who was suddenly seized with jaundice accompanied by vomiting, and died the same night in a state of coma. A calculus was found sticking in the gall duct, and the duct was ruptured. On the other hand, I have described a remarkable case in which a calculus impacted in the common duct was