EXCRETORY ACTION OF THE LIVER. 407 



blood becomes mixed with that from the hepatic artery, and from this mixt- 

 ure the cholesterine is separated. It is necessary only that blood, contain- 

 ing a certain quantity of cholesterine, should come in contact with the bile- 

 secreting cells, in order that this substance shall be separated. The fact that 

 it is eliminated by the liver is proved with much less difficulty than that it 

 is formed in the nervous system. In fact, its presence in the bile, and the 

 necessity of its constant removal from the blood, consequent on its constant 

 formation and absorption by this fluid, are almost sufficient in themselves 

 to warrant the conclusion that it is eliminated by the liver. 



In treating of the composition of the faeces, the changes which the choles- 

 terine of the bile undergoes in its passages down the intestinal canal have 

 been so fully considered that it is not necessary to refer to this portion of 

 the subject again. But one examination only was made of the quantity of 

 stercorine contained in the daily fsecal evacuation ; and assuming that 

 the quantity of cholesterine excreted by the liver is equal to the stercorine 

 found in the evacuations, the quantity in twenty-four hours is about ten and 

 a half grains (0-68 gramme). This corresponds with the estimates of the 

 daily quantity of cholesterine excreted, calculated from its proportion in the 

 bile and the estimated daily quantity of bile produced by the liver. 



To complete the chain of the evidence leading to the conclusion that 

 cholesterine is an excrementitious product which is formed in certain of the 

 tissues and eliminated by the liver, it is necessary only to show that it may 

 accumulate in the blood when the eliminating action of the liver is inter- 

 rupted. 



In a case of simple jaundice from duodenitis, in which there was no 

 great disturbance of the system, a specimen of blood taken from the arm 

 presented undoubted evidences of the coloring matter of the bile, but the 

 proportion of cholesterine was not increased, being only O508 of a part per 

 thousand. The faeces contained a large proportion of saponfiable fat, but no 

 cholesterine or stercorine. 



In a case of cirrhosis with jaundice, there was ascites, with great general 

 prostration. This patient died a few days after the blood and faeces had 

 been examined, and the liver was found in a condition of cirrhosis, with the 

 liver-cells shrunken and the gall-bladder contracted. In this case the blood 

 contained 1-85 of a part of cholesterine per thousand, more than double the 

 largest quantity found in health. The faeces contained a small quantity of 

 stercorine. 



Inasmuch as cases frequently present themselves in which there are evi- 

 dences of cirrhosis of the liver with little if any constitutional disturbance, 

 while others are attended with grave nervous symptoms, it seemed an inter- 

 esting question to determine whether it be possible for cholesterine to accu- 

 mulate in the blood without the ordinary evidence of jaundice. An oppor- 

 tunity occurred of examining the blood in two strongly contrasted cases of 

 cirrhosis, in neither of which was there jaundice. One of these patients had 

 been tapped repeatedly about thirty times but the ascites was the only 

 troublesome symptom and the general health was little impaired. In this 



