It might naturally be thought that the exclusion of bile from the intestines would seriously modify the processes of digestion, and therefore it will be well to give a summary of the effects upon the alimentary tract of the exclusion of bile from it.

According to A. Schmidt when the bile cannot reach the intestines the amount of gastric juice is increased, and hence there is considerable hyperacidity. It is not known whether there is any change in the pancreatic secretion or the succus entericus. The view is commonly held that jaundice causes constipation, but clinical observations made with especial care teach the reverse and show that the motions may be copious and loose. This certainly is my own experience, and it is what would be expected, considering the presence of fat which would be absorbed were it not for the absence of bile. F. Miiller from clinical observations, which it may be mentioned agree with those reached by experiment upon animals, concludes that the absence of bile from the intestines does not interfere with the assimilation of carbo-hydrate, protein, or inorganic matter, but the absorption of fat is greatly impaired. The stools are consequently fatty. Their amount, provided that the diet is unaltered, is three or four times the normal. The proportion of water is not altered. The specific gravity falls below 1,000, the fatty material floats on water, the reaction becomes strongly acid from the presence of free fatty acids, the needle-shaped crystals of which may be seen under the microscope and cause the greyish-white fatty stool to scintillate. By far the greater part of these crystals are the calcium salts of palmitic and stearic acids. The proportion of fatty acids or soaps to neutral fat is the same as in health namely 3-1. We learn, therefore, that one function of bile is to render fatty acids and soaps capable of absorption, and that therefore when it is absent they are not absorbed.

Bile itself has no antiseptic properties, for it does not hinder the growth of micro-organisms, indeed, as is well known, it often becomes infected in the gall-bladder, and there is no evidence that the absence of bile from the faeces leads to decomposition of them; indeed, one observer finds a remarkable diminution of bacteria in the faeces, and if the absence of bile led to an abnormal decomposition of faeces we should expect jaundice to be followed by enteritis, but this is not the case. The peculiar smell of the faeces when no bile is present is probably due to fatty acids. The wasting, often extreme, which is seen in those who have been jaundiced for some time, even when the cause of the jaundice is not malignant disease, is due chiefly to the failure to absorb fat. Lastly, it should be added that there is some evidence that bile circulating in the blood increases the protein decomposition in the body.

Clinical experience teaches us that persons who have jaundice have a great repugnance to fats, and that is what would be expected, seeing the large amount of unused fat which is present in the stools. Hence, whatever be the cause of the jaundice, the patient should take no fat. It might be thought that it would be a good thing in such cases to inject olive oil under the skin. I have injected three drachms, night and morning, of sterilized olive oil under the skin of a patient who had an intestinal fistula high up in the jejunum, so that much of his food taken by the mouth passed out unutilized, and in whom it was impossible, owing to a kink, to inject food into the lower piece of ileum. All the oil was absorbed, and the patient, by dint of feeding this way, by the mouth, and by the rectum, gained weight and strength until he reached such a condition that it was possible by resection to restore the continuity of the gut. He made a complete recovery. The oil was injected under the skin of one thigh each morning and under the skin of the other each evening. It would be worth while to try in a case of long lasting jaundice whether fat could be introduced this way, but it must be remembered that only 300 calories of food a day can be thus given, for a very bulky injection is too painful.

The wasting seen in those who are jaundiced, even when the jaundice is not due to malignant disease, is often in excess of that which can be attributed to the absence of fat from the food. There are several reasons for this. The bile in the blood leads to dyspepsia, often the cause of the jaundice gives rise to dyspepsia, and perhaps the bile in the blood leads to an excessive protein decomposition, but this is not certain.

It is clear, therefore, that the patient should take plenty of carbo-hydrates and proteins, as much indeed as his limited powers of digestion will allow, and his feeding should be little and often, especially as we have seen that he suffers from an excessive secretion of gastric juice. Many vegetables are either difficult of digestion or contain so much water that their nutritive value is low, but lentil flour, which contains 22 per cent of protein and 65 per cent of carbo-hydrate and only 1.5 per cent of fat, is a very good food for those with jaundice. Potatoes properly cooked are desirable, for they contain about 20 per cent of carbo-hydrate and very little fat. They should be steamed or cooked with their skins on, for if not they lose a considerable part of their proteins and salts. Bread, toast and biscuits are excellent, especially with jam and marmalade. If it does not cause indigestion maltine is valuable. Rice and tapioca, sago, arrowroot, grapes and bananas may all be given. Most infants' foods contain very little fat, and so they, too, may be used, and as whey and buttermilk are each of them milk from which the fat has been removed, they are useful to drink. The patient will get some protein in each of the articles of food already mentioned, but he may in addition take fish, meat, chicken and game. Inasmuch as the degree of indigestion varies much in different cases, it is difficult to lay down any exact rules, but the attempt must be made to keep up the patient's weight by foods judiciously chosen from among those just mentioned. Tea, coffee, and a moderate amount of alcohol may be taken.