all that is required, and not, as was formerly supposed, a mysterious production from it of albumen, fibrin, and casein, which it did not previously contain. For we know that food, both animal and vegetable, does contain, ready formed, these constituents of the blood. Now, this solution is effected, that is, chymification is completed, without the aid of the bile. It was till lately supposed that one use of the bile was to neutralize the acid of the chyme, and this notion rested on the assumed fact of the bile being alkaline. But if Bouisson's and Dr. Kemp's late researches are accurate, the bile is neutral, and therefore the use referred to is imaginary; unless, as Dr. Budd (p. 30) conjectures, the bile is decomposed in its passage along the bowels, its soda uniting with the acid of the chyme. Dr. Prout's opinion (see Stomach and Renal Diseases, p. 467, ed. 1843,) seems to be, that the chloric acid of the chyme is derived from the common salt existing in the blood and in the stomach: that the salt suffers decomposition; chloric acid is set free, and the soda remains in the stomach, or is absorbed (both of these probably happen) again into the blood. Part of it, a small portion, goes, as Dr. Prout thinks, to maintain the weak alkalinity of the blood: the greater portion returns to the liver, there to be eliminated and to reunite, in the duodenum, with chloric acid. Thus, as it were, an endless cycle of union and separation of part at least of the constituents of the common salt of the blood, takes place. And may we not suppose that something of the same kind happens as regards the carbon of the decomposed tissues, elicited in the bile? Having undergone some purifying process in the course of that elimination, it is fitted for again serving as respiratory food, and is, if we may use the phrase, economically reabsorbed. This, supposing the present theories of respiration and animal heat to be true, appears to us the true explanation and history of the series of changes going on in the duodenum.

It must not, however, be supposed that the bile furnishes anything approaching to the principal proportion of the carbon, excreted by the lungs and skin. The quantity of carbon supposed to be eliminated by these two channels, is said to average 13 ounces daily, (this is Liebig's computation.) Now, the carbon of the bile, even at the highest estimate, does not exceed three ounces; and if our calculation of from 11 to 14 ounces be regarded as expressing the average daily secretion of bile, the carbon contained in it is about one ounce only.

Agents affecting the bile. At the conclusion of his introductory chapter, and before he proceeds to the main business of the work, Dr. Budd makes some pathological and therapeutical observations which perhaps might have been reserved for a subsequent part. Among cholagogue medicines he specially mentions mercury, iodine, muriate of ammonia, and taraxacum. For our parts, we have never observed peculiar cholagogue properties in muriate of ammonia, nor yet in rhubarb, which Dr. Budd subsequently instances. Bonnet enumerates rhubarb as one of the irritating substances, and unskilfully employed by some practitioners in hepatic disease. We cannot say we have found it to be irritating; assuredly we have not found it to be specially cholagogue. We are surprised that in the brief list of drugs particularly adapted for "rendering the liver more active, and increasing in this way the secretion of bile, (p. 35,) Dr. Budd should have omitted colchicum, and even colocynth,

but the former more particularly. Perhaps next to mercurial preparations, there is no agent more remarkable, in that way, than the one just named. Nitric acid also, not here referred to by Dr. Budd, seems in some cases notably to promote the action of the liver.

DISEASES OF THE LIVER.

The first morbid condition which Dr. Budd

treats of is congestion. (p. 38.)

Congestion. The common and usual form of congestion of the liver is that of the hepatic vein and its capillaries; and that form may be caused by any disease in the heart or lungs tending to obstruct the return of blood by the hepatic veins. If, while the hepatic veins and their capillaries are thus congested, the portal vein and the capillaries immediately branching from it are empty, the appearance called mottled liver is presented, caused by the central vessels of the lobules being full of blood, while those on their margins are void of it. And just in proportion as the vessels continue to be distended in a direction distal from the heart, and as the portal capillaries which form the margin of the lobules become filled gradually, will the mottled appearance merge into a homogeneous redness. And now, in addition to sanguineous, will biliary congestion begin to take place; and this plainly in consequence, in the majority of cases at least, of the pressure of the distended blood-vessels on the minute branches of the biliary ducts, whereby the discharge of bile along these ducts is impeded. The general result of this state of things is hyperemia, and a state of distension of the biliary vessels analogous to hyperemia, but for which we have no exact name. The liver, of course, becomes enlarged, and its colour, when an incision is made, is a deep reddish-brown or black.

The diagnostic indications of this state are, the dropping of the liver several inches (more or less, according to the degree of enlargement,) below the ribs, and a fulness felt by the patient and perceived by the physician in the right hypochondrium. There is not "in general" pain (p. 41); never, we should say, in this simple form of congestion, until its prolongation begins to give rise to inflammatory action. And even then pain is hardly or not at all experienced, until the peritoneal investments begin to suffer, and the affection becomes what Bonnet calls hepatoperitoneal. (See Article V. of our Number for July, 1843.)

Besides affections of the heart and lungs, the hot stage of ague, and occasionally purpura hæmorrhagica, (if we are to credit Dr. Budd,) are attended with hepatic congestion. Andral states (p. 10, tome 4, of his Clin. Med. ed. 1827,) that he has often observed great congestion of the liver in persons dead of scorbutic disease. In these cases the spleen was also hyperemic, but the congestion of neither organ had any connexion with inflammatory action. He seems to be of opinion that it is in diseases attended with a great diminution of the fibrin of the blood, that congestion of the liver and spleen are most apt to occur.

Congestion confined to the portal system is, according to Mr. Kiernan, who alone gives any account of it, a rare affection, occurring, so far as his experience goes, only in children.

Dr. Budd's remarks on the treatment of congestion of the liver, are extremely concise, and as vague and general as possible. (p. 43.) In congestion depending on obstructed circulation through the heart, he advises bleeding, purgatives, diuretics, rest,-those measures, in short, which

peculiarly relieve cardiac disease. He does not mention blistering and friction over the heart, yet these are important means. "When the liver," he remarks, "cannot free the blood from the principles of bile, or the skin becomes sallow, the patient should carefully abstain from rich meats and fermented drinks, which would render the liver still more inadequate to its office, and increase the biliary disorder." (p. 43.)

Purpura hæmorrhagica, scorbutic disease, and any affections tending to diminish the fibrin of the blood, require, we need not remark, the mineral acids and the bitter extracts. We have witnessed great advantage from the compound infusion and spirit of armoracia, taken twice or thrice a day, with ten drops of nitric or chloric acid added to each dose.

We may remark, before quitting this lesion, that in long-continued congestion of the liver, the nucleated cells, the seats of the biliary secretion, are apt to be obliterated, or at least to suffer in their structure, and, in this way, the function of the liver is liable to be materially and perhaps permanently impaired.

Dr. Budd devotes chapter second to the consideration of "Inflammatory Diseases of the Liver." The first section of the chapter is allotted to suppurative inflammation and abscess. Before proceeding, however, to the discussion of the matters just named, he touches on and condemns the usual classification of inflammatory diseases of the liver. The wonted division of such diseases is into acute and chronic, which he characterizes as "essentially faulty," (p. 46;) and on the very just grounds, that it is inaccurate, and corresponds not with, or rather misleads us in regard to, the actual facts. Deep-seated inflammation of the liver may, if not very extensive, run rapidly into abscess, without very striking symptoms of any kind, and might therefore be called "chronic during the life of the patient, while inflammation involving the surface of the liver, even of such a kind as causes the slow effusion of coagulable lymph only, will be attended with well-marked local symptoms, with great pain and tenderness, and would be termed acute." (p. 46.)

The author therefore thinks that, in the case of liver-disease, as well as of every other, morbid affections should as nearly as possible be named from their causes. He therefore divides inflammatory affections of the liver into-1, Suppurative; 2, Gangrenous; 3, Adhesive.

Suppurative inflammation. Perhaps this section on suppurative inflammation and abscess of the liver is the most interesting and important in the entire volume before us. Dr. Budd's object is to show, that by far the majority of cases of abscess of this viscus are owing to "suppurative inflammation of some vein, and the consequent contamination of the blood by pus." (p. 49.) It had been long observed that, subsequently to large wounds or surgical operations, and where suppuration had taken place, pus often formed in remote parts, as, for example, in the interior of joints, in the lungs, in the liver. This was called and supposed to be a deposit of pus: it was imagined that the pus was not formed at the place where it was found, but was brought thither from the primary suppurating surface by the vessels, and then deposited or excreted. But when it was ascertained that pus-globules are nearly twice as large as blood-globules, it became manifest that if the vessels deposited the former, they must, à fortiori, let the latter also escape. But in these secondary abscesses, while there was purulent, there was no sanguineous extravasation or

deposition. It hence became manifest that the pus must be formed at the place where it was found, by the usual process of a local inflammation. The experiments of MM. Dance and Cruveilhier and of Dr. Saunders also showed that the veins must be the channel which transport the globule or globules of pus, which, entering these at some suppurating surface, and becoming arrested in the minute capillary vessels of the lungs or liver, cause those secondary abscesses of which these two organs, both from their peculiar structure and from the fact that all the blood of the body passes through them, are so frequently and remarkably the seat. Now, for the important practical elucidation derivable from the explanation just given, in regard to hepatic abscess so often consequent on dysenteric affections, and on wounds or diseases of the intestines, in which suppuration had taken place.

The author gives a good many cases from Cruveilhier, Andral, Louis, Annesley, and from his own practice on board the Dreadnought, illustrative of the relation of cause and effect, in the majority of cases, between ulcerated states of the intestinal mucous membrane and hepatic abscess. And, in our opinion, he most satisfactorily establishes this connexion. Louis, Andral, and Annesley notice the connexion, and, indeed, it had been long observed; but none of them appear to have surmised the nature of it. Dr. Budd would appear to hold (p. 62) that even in cases where hepatic disease seems to precede the dysentery and to cause it, yet that the formation of the hepatic abscess is still consequent on, and subsequent to, the dysenteric affection. In India, there are often cases which commence with biliary disturbance; by and by, fatal and rapid dysentery ensues, and the patient, on post-mortem inspection, is found with abscess of the liver, fully formed. Now, it might at first be suspected that the formation of the abscess, or the peculiar form of inflammation which caused it, preceded the dysentery.* If we understand Dr. Budd aright, (pp. 61-3,) the contrary is the case. The primary hepatic affection was not suppurative, but adhesive inflammation, the result of spirit-drinking, and liable to terminate in induration and cirrhosis,--seldom or never in abscess. But, possibly, the passage of acrid bile, the result of this primary affection, may have caused or predisposed to dysenteric inflammation, and during the resulting suppuration of the intestine, a globule (for often one seems sufficient) or globules, passing up a hemorrhoidal or other intestinal vein, has become arrested in the portal capillaries of the liver, inducing suppurative inflammation with abscess, in addition to the prior-existing adhesive inflammation of the organ.

But it is not necessarily dysenteric affections of the bowels alone, and the consequent ulceration; but ulceration from any cause, and situated in any part, distal of the liver, in consequence of which the veins proceeding from the part discharge into the portal vein, which may give rise to hepatic abscess. Accordingly we have (at pp. 65-7) cases referred to by Dr. Budd, in which the ulceration was seated in the stomach, in the gall-bladder, and hepatic ducts respectively. The author cites a case of Mr. Busk's, in which the splenic vein was the seat of the primary suppuration or ulceration.

• This view was taken many years ago by Dr. Archibald Robertson in his excellent Thesis (Edin. 1817,) De Dysenteria regionum Calidarum."

At pp. 70-1-2-3, the author proceeds to confirm the views which we have now described, but there is nothing in this part requiring particular remark.

The "changes of structure," to which suppurative inflammation of the liver leads, is next considered, (pp. 74 et seq.)

Suppurative inflammation of the liver commences in, and often does not extend beyond, the lobular substance. If, indeed, the inflamed part approach, in any direction, the peritoneal surface of the organ, or be closely contiguous to a trunk of the hepatic vein, adhesive inflammation of the peritoneal lining, in the former case, and internal inflammation of the hepatic venous branch, in the latter case, may ensue. However, these secondary results are not usual. Dr. Budd has never seen any branch of the portal vein thus secondarily involved, though Dr. Russell of Birmingham has. The author attributes this difference to the circumstance of the coats of the branches of the portal vein being thicker than those of the hepatic, and also surrounded by areolar tissue.

The abscess or abscesses, if they have led to a speedily fatal issue, are bounded simply by red and softened parenchyma; and it may be laid down as a general rule, that, in proportion to the length of time the abscess has existed, (supposing the consequence not to be immediately fatal,) do the walls of the abscess assume more and more density and thickness. Sometimes, however, the contents of the cyst augment, and the pressure causes irritation of the internal walls, followed by ulceration and ultimate gradual extension of the abscess. The abscess, may of course, discharge in any direction; as it reaches the surface of the liver, it excites inflammation in the hepatic peritoneum, by which adhesion between this and the parietal or diaphragmatic peritoneum is effected or else the adhesion takes place between the hepatic surface and that of the stomach, duodenum, or bowels; or the abscess may discharge, no such adhesions having been formed, directly into the abdominal cavity. This termination, as it is more hazardous, so it is rarer than the others.

:

The sizes of these abscesses are sometimes amazing. In one of Annesley's cases, the abscess contained 90 ounces: in one of Dr. Inman's of Liverpool, the quantity was 13 pints!

The symptoms of suppuration of the liver and of the formation of abscess, are generally obscure or rather equivocal, and sometimes extremely so. Though there occur occasionally, as concomitants of inflammation tending to abscess, pain, fulness in the hepatic region, and jaundice, yet all of these may be absent, or present in an almost unappreciable degree only, and may moreover be caused by other affections; such as irritation or inflammation of the gall-ducts. When the abscess or abscesses are small and central, and when they do not cause any general obstruction to the passage of the bile, neither tumefaction nor jaundice ensue; nor, in the same circumstances, is pain usually felt. Our diagnosis will, however, be materially facilitated should dysentery be present, or there be any suppurating mucous or cutaneous surface, or any extensive wound, accidental or surgical. Pain in the hepatic region, or fulness there, or jaundice occurring in these circumstances, must awake our anxiety and suspicion. The occurrence of a well-marked rigour would, of course, give additional force to other proofs or presumptions.