As regards pain in the right shoulder, which Dr. Budd considers in connexion with hepatic abscess, it occurs, according to our experience, less in acute than in chronic affections, and in all forms of hepatic disease or irritation. Andral and Louis appear to doubt whether it is ever present except when the lung or pleura is affected, and to place little or no faith in it as a sign of hepatic disease. It is usually said that it can indicate inflammation of the convex surface and of the right lobe of the liver alone, but it was present in a case of Andral's, cited by Dr. Budd himself, in which the abscess was on the under surface of the right lobe. "The pain," observes the author, "is, in fact, as it has always been represented to be, a sympathetic pain, like the pain of the knee from disease of the hip." (p. 84.) Dr. Budd is, no doubt, aware, that the pain is accounted for from the fact, that the phrenic nerve is derived from the fourth cervical nerve, and that this nerve also supplies the muscles and integuments of the neck and shoulder: it follows that, if the diaphragm should be irritated or stretched by enlargement of, or inflammatory action in, the liver, the nerve named from it may be affected; and, circuitously, the branches of the fourth cervical nerve which go to the neck and shoulder. We have often met with cases of hepatic disease in which the pain was felt in the left shoulder, and about the scapular muscles: it may be from the centre or left portion of the diaphragm having been peculiarly

affected.

As to rigidity of the right rectus muscle, stated by Mr. Twining to be one of the most certain indications of deep-seated (?) abscess of the liver, we, for our parts, have never met with it, unless when the parietal peritoneum participated in the inflammation of the subjacent hepatic peritoneum. Then there was a slight apparent tension, probably owing to irritation of the rectus muscle. But why deep-seated abscess of the liver should cause rigidity of this muscle, unless that abscess, by enlarging greatly the bulk of the organ, gave rise to distension of the muscle, and thus elicited natural or spasmodic contraction of it, it were difficult to divine.

As to cough and vomiting, both of which Louis distrusts as symptoms of hepatic abscess, and which Dr. Budd confides in, describing them merely as "sympathetic disorders, depending solely on irritation of the liver," (p. 85,) the former is to be accounted for in the same way as the pain of the shoulder, the cough being simply caused by spasmodic action of the diaphragm, in consequence of irritation of its nerve by the adjacent enlarged or inflamed viscus; the latter occurs when the irritation of the liver has involved the duodenum, and when, besides, this intestine is excited by the acrid bile, which, when inflamed, the liver is apt, in the first stage of inflammatory action, plentifully to excrete.

At page 89, occurs a remark so extraordinary that we must quote, and we shall do so without a single observation. The fatalness [of hepatic abscess] has no relation to the outlet by which the matter is discharged. I have met with several cases in which the abscess opened through the abdominal parietes, and all of them proved fatal; so that it seems doubtful whether such an opening be more favorable than one into the intestine or lung."

The author's remarks on the treatment of suppurative inflammation

and abscess of the liver are, on the whole, judicious, yet, as we shall presently see, there are some things to be objected to. He advises that, if the inflammation be due to phlebitis, consequent on a wound, &c., means should be taken to prevent the ingress of more pus into the circulation. How is this to be effected? The strength of the patient is also to be supported, and the hepatic inflammation abated, as much as possible, by antiphlogistic means. The author then approaches the quæstio vexata of the value of mercury in hepatic affections:

"In this country, mercury has generally been resorted to, when the local symptoms have led to the suspicion that the liver was diseased; but, I fear, with no benefit to the patients. It has been well observed by Abercrombie, 'In the liver-diseases of this country, mercury is often used in an indiscriminate manner, and with very undefined notions as to certain specific influence, which it is supposed to exert over all the morbid conditions of this organ. If the liver be supposed to be in a state of torpor, mercury is given to excite it; if in a state of acute inflammation, mercury is given to moderate the inflammation and reduce its action." (p. 90.)

Now, greatly as we respect the authority of the late Dr. Abercrombie, and that of Dr. Budd, we must yet be permitted to express our opinion, that the use of mercury is defensible both in many states of torpor and in many also of acute inflammation of the liver. In many cases of tumid and tender liver, accompanied with equivocal marks of diminished secretion, as for example pale or white stools, no agent more rapidly reduces the volume and restores the action of the organ, than mercury. Again, he would be a bold man, who in almost any case of "acute inflammation' of the liver, except that caused by occlusion of the common duct, would refrain from using mercury, to a greater or less extent, and in conjunction, of course, with other means. We, for our parts, should consider that a practitioner who had failed to do so, had hardly given his patient all the professional aid which he might and ought to have done. We do not, of course, advocate the use of mercury after suppuration or abscess. Its very object is to prevent the occurrence of these, by resolution. After either of these events has taken place, mercury is to be withdrawn, if it have been used, and all our attention given to support the strength of the patient.

In reference to opening, by incision, abscesses of the liver, we entirely agree with the following observations of Dr. Budd; and the result of his experience of the method suggested by Dr. Graves, deserves publicity, though it would have been desirable had he entered into some further explanation and details.

"I would, then, never recommend opening an abscess of the liver, unless assured by circumscribed oedema, or a slight blush on the skin, that union had taken place between the integument and abscess. When these signs are wanting, and the skin has its natural appearance and colour, we can never be sure that adhesions have formed, and if we thrust a knife into the abscess, we run the risk of discharging the matter into the cavity of the peritoneum.

Dr. Graves has ingeniously recommended a mode of proceeding, by which he supposes this danger to be obviated. It is, not to open the tumour at once, but to make an incision across the most prominent part of it through the abdominal muscles, so as to reach the peritoneum, without dividing it, and to fill up the wound with a pledgit of lint. The object of this is, to excite circumscribed

inflammation of the peritoneum, which may produce adhesion between the reflected layer of the peritoneum and the layer covering the abscess. The abscess is then allowed to open of itself. I have tried this mode of proceeding twice, but with very unsatisfactory results." (pp. 92-3.)

The author, we need scarcely observe, condemns the use of the exploratory needle, as practised in India, and most truly observes:

"An occasional instance of success will, I fear, be a poor set-off against the cases in which the operation has done mischief, or failed of doing good." (p. 94.)

Gangrenous inflammation. The next section of this chapter is devoted to the consideration of " 'gangrenous inflammation" of the liver. It is very short, but we shall not make any remark upon it, except that Dr. Budd entertains the opinion that gangrenous inflammation is often disseminated from the extremities or from remote parts to the liver, in precisely the same way as suppurative inflammation is shown often to be in the former section, namely, by the septic matter entering a vein, passing to the liver, and there causing the same species of inflammation as the primary one. He gives a case (p. 99,) in which gangrene of the liver, lungs, and spleen, appeared to result from mortification of the toes from cold.

Adhesive inflammation. Section third (pp. 105 to 135 inclusive) is allotted to the description of adhesive inflammation of the liver. After briefly noticing or rather simply enumerating several causes of adhesive inflammation of the peritoneal covering of the organ, by which it is apt to be agglutinated to contiguous parts, the author proceeds (p. 107,) to consider "deep-seated adhesive inflammation." Sometimes the effused lymph is confined wholly to the cellular tissue surrounding the larger portal canals, the other parts of the viscus being healthy; at other times, the effusion of lymph takes place around the smaller twigs of the portal vein, those, namely, which divide the lobules. Hence the whole substance of the liver is rendered tough and somewhat white, by this deposition of coagulable matter, and the capsular as well as the peritoneal investment of the liver, are puckered by the new tissue contracting in the tracks of the interlobular veins, the lobules themselves retaining their volume. This form of adhesive inflammation and pathological change, called "hobnailed-liver" in this country, is designated" cirrhosis" by the French, from the Greek word kippos, fulvus, yellow, which is the colour which the liver presents, in this disease. This colour seems to be owing to the contractions caused by the effused lymph about the small gall-ducts interrupting the flow of bile among these, and thus giving to the lobules in which the bile is retained, a flavous hue.

Cirrhosis. In cirrhosis, the liver is at first much larger, afterwards much smaller than in health. In the first stage of the disease, the effusion of lymph and serum, together with the accumulation of bile in the portal capillaries, causes a large increase in the bulk of the organ; but when the inflammation has run its course, absorption removes the serum: those portions of the lobular substance, from which the escape of bile is permanently obstructed, by the contractions already referred to, become atrophied; and hence the liver subsides to a volume less than the normal. Dr. Budd mentions two facts illustrative of the great augmentation and subsequent diminution of the liver.

XLI.-XXI.

4

"Some time ago, in a case of advanced cirrhosis, I found a band of cellular tissue some inches in length, uniting the liver to the spleen. The adhesions must have formed when the organs were in contact, and have been drawn out as one or other contracted.

"In another case of advanced cirrhosis, I found the convex surface of the liver united to the diaphragm by tufts, or bands of false membrane, an inch in length. The parts of the liver at which these tufts were inserted, were hollow or depressed, and when all the tufts were divided, the surface of the liver was very uneven.

"Here, as in the case in which the liver and spleen were united, the adhesions must have formed when the surfaces were in contact, and the bands have been drawn out as the surfaces receded from each other. In both cases, these tufts or bands were evidence of the contraction of the liver, after adhesions had been formed. The degree of contraction being different in different parts, the surface of the liver becomes uneven." (114-15.)

Cirrhosis, both in this country and in France, seems to be chiefly caused by the constant use of alcoholic liquors. Andral considers that the hepatic disease is the consequence either of previously induced irritation on the duodenal mucous membrane, or that the alcohol is directly absorbed and carried into the liver by the portal veins. Dr. Budd regards the latter as the correct explanation. (p. 117.)

Cirrhosis is, commonly, insidious in its progress. It, like most hepatic diseases, is attended with structural change, is not accompanied with much or any suffering, unless the peritoneal investment of the liver is implicated. At other times, accidental circumstances may bring on a sudden access of inflammation, when, the train having been long prepared by spirit-drinking, the change constituting cirrhosis takes place promptly and with emphatic signs of inflammation. More usually, however, as we have remarked, the gradually increasing condensation of the liver and the abolition of the cells and their function in a great part of it, gives rise to sallowness of complexion, pale stools, and at length to ascitic symptoms, owing to embarrassment of the portal circulation. Ascites, indeed, Dr. Budd observes (pp. 121-2,) is an important symptom, because it occurs in few other diseases of the liver. "Frequently, however," he says, further, "together with the ascites, there is oedema of the legs, but unless there be some disease of the heart or of the kidneys, the œdema of the legs is always consecutive to the ascites." (p. 122.)

A jaundiced colour of the countenance is, however, less common, and is less in degree, than in abscess of the liver, for in the latter disease, it is only a part or parts of the organ that are affected; the remainder being usually competent to their function: in the former disease, the whole liver is generally involved.

The livid complexion and the languor accompanying the disease are thus explained:

"The obstructed circulation through the liver serves also to explain in part, the sallow, dingy complexion, so constantly observed in advanced stages of cirrhosis. Part of the portal blood, instead of traversing the liver, finds another way, through the abdominal parietes, to the heart. This part of the blood cannot be purified, or freed from the constituents of bile, as it should be, and must consequently contaminate the whole mass of blood with which it is mixed. In this respect, cirrhosis offers an analogy to those cases in which there is a mixture of venous and arterial blood, in consequence of communication between the two sides of the heart. "The emaciation and the loss of strength-other constant symptoms in cirrhosis

-depend perhaps in part on impairment of all the assimilating functions, by the habits of life that induce cirrhosis; but they are no doubt mainly owing to the obstructed circulation through the liver, and the imperfect secretion of bile.

"The obstructed circulation impedes, as we have seen, the absorption of water, and also of other substances that contribute to nutrition, by the veins of the stomach and intestines. Imperfect secretion of bile tends to impair nutrition in two ways. The bile, which no doubt performs an important part in digestion, flows in too small quantity into the duodenum, and digestion is in consequence imperfectly performed; and, on the other hand, some of the principles which should be eliminated as bile, remain in and contaminate the blood; causing languor and drowsiness, and weakening in some degree all the assimilating functions." (pp. 124-25-26.)

Cirrhosis is distinguished from chronic peritonitis, by the sallow hue of countenance, the amount of ascitic effusion and the permanency of it, and by the former occurring generally in spirit-drinking subjects, and usually not till after the 30th year. As regards treatment, it is obvious, that after effusion of lymph into the substance of the liver, no means are the least available. It is only therefore during the stage of the malady prior to effusion, in short, during the acute inflammatory stage, that treatment can be serviceable. But, it has been already remarked, that the disease is extremely obscure, in many cases, in its commencement. Hence Dr. Budd's remark is a very just one:

"In the person of a spirit-drinker, we should never neglect pain and tenderness in the region of the liver, especially if associated with some degree of fever." (p. 129.)

Bleeding of course will be requisite, but this measure ought to be practised with the recollection that drinkers are easily depressed by slight depletion. As Dr. Budd observes, an incautious bloodletting may, in such subjects, lead to delirium tremens or some even more formidable affection. Blistering, mercury judiciously employed, combined with the iodide of potassium, diuretics, light tonics, warm clothing, friction, a restricted use of alcoholic drinks, or a total abandonment of it, are the curative means which we must have recourse to. Friction, with mercury, and iodine over the region of the liver will also be expedient.

We pass over, entirely, section 4 of chapter ii, since great part of the information it contains has been incidentally given in the course of the quotations and observations already made. This section is occupied with the subject of "inflammation, suppurative and adhesive, of the branches of the portal vein, and with inflammation of the hepatic vein."

Inflammation of the gall-bladder and ducts. Section 5 (pp. 149 to 195 inclusive) is one of considerable practical interest and importance. In it are discussed various forms of inflammation of the gall-bladder and ducts. Catarrhal and suppurative inflammation is the species first handled. The former of these is a mild, and for that reason, a not easily detected disease. It is seldom or never fatal. "It happens, however, not unfrequently that on squeezing the hepatic ducts, a viscid whitish fluid oozes out, which, on examination, through the microscope, is found to be chiefly made up of the prismatic epithelial cells of the gall ducts." (p. 151.) The author then adds that the symptoms we might "expect" in catarrhal inflammation would be slight feverishness, and slight enlargement of the liver and jaundice, slight also, if the ducts were obstructed by the viscid secretion