here it may relieve for the moment, almost invariably does harm. It increases the activity of the liver at first, but seems to leave it weaker than before; and if frequently resorted to, the nutrition of the patient, impaired by the original disease, is still further impaired by the drug. In all such cases, we should be content with milder medicines, which promote the secretion of bile without having any permanent deleterious effect on the system. The best medicine of this class is taraxacum, which may be given alone, or in conjunction with the nitromuriatic acid.

In all organic diseases of the liver, where the secretion of bile is habitually deficient, and nutrition is impaired in consequence, the person should be warmly clad, and should avoid all causes of exhaustion. Fatigue, and lowering remedies, exhaust the strength, and draw, as it were, upon the capital of the patient, when this is very difficult to recruit. The disease destroys its victim, not by sudden illness, but by gradually wasting the strength. The more, therefore, this is economized, the longer will life be preserved.

The Bile altered in Quality.-The bile found in the gall-bladder after death varies much in color and consistence in different cases. In some, it is of a light yellow, and thin, or watery; in others, it has a reddish cast; in others, again, it is of a dark olive, and thick, and viscid; but little is known of the changes in its chemical composition that correspond to these changes in its outward characters. Few analyses have been made even of healthy human bile. The attempts of chemists to ascertain the composition of bile have most of them been made on ox-bile, which can be more readily obtained fresh, and can be obtained in larger quantity than human bile. It cannot, therefore, excite surprise that little is yet known by chemical analysis of the changes produced by disease in human bile. The only morbid states of bile ascertained in this way consist in the presence of a free acid; in the presence of urea; in the presence of some medicines that pass off in the bile; and in an excess or a deficiency of the water, biliary matter, or mucus, of the bile.

The presence of a free acid in bile found in the human gall-bladder after death is not a very uncommon occurrence. Instances have been related above in which it occurred.

1. In a woman who died, in the month of July, of jaundice from suppressed secretion, with symptoms of cerebral poisoning. (See page 256.) Rapid decomposition of the body took place, and when

it was examined thirty-six hours after death, the gall-bladder contained about a drachm of chocolate-colored bile, which, to judge by the reaction of blue litmus-paper, was intensely acid. Litmuspaper placed in contact with the liver itself was immediately changed to a bright red.

2. In a man (p. 312) who died in January, 1852, in a state of great exhaustion, from scrofulous enlargement of the liver and chronic abscess of the left kidney. The bile in the gall-bladder was of a pale orange color, and had a distinct acid reaction. The body, which was examined thirty-two hours after death, presented no striking marks of decomposition.

In the first edition of this work, reference was made to the case of a woman who died in the autumn of 1843, in King's College Hospital, of cancerous ulceration of the rectum and granular kidney, in which this condition was observed. The bile reddened litmus-paper distinctly, and from its being of a pale amber color, no doubt could exist that the change of color in the paper was owing to the action of an acid.

In the autumn of 1849, I met with very pale-colored bile, distinctly acid, together with three gall-stones, in the gall-bladder of a man who died in King's College Hospital of chronic granular disease of the kidney, with recent inflammation of the pericardium and pleura. The bile in this instance presented other unnatural appearances; containing numerous flaky masses which were found to consist of epithelium, and many amorphous masses which seemed to consist chiefly of biliary coloring matter.

I have met with several other instances in which the bile, and the liver itself, had a very distinct acid reaction; and in most of them the bile, as in the instances noticed above, was unnaturally pale. Deficiency of the proper biliary coloring matter seems to promote the occurrence of an acid condition in the bile.

The immediate cause of this acid condition of the bile is most probably decomposition of the bile, or of the mucus it contains.

When ox-bile is allowed to decompose exposed to the air, it becomes after some days distinctly acid; and if it be then neutralized, it becomes, on further standing, acid again. It is a curious circumstance, tending to show the complementary relation that exists between the bile and the urine, that decomposition, which renders the urine alkaline, renders the bile acid. The decomposition of the bile takes place, of course, more rapidly in hot weather, and is much pro

moted by the mucus it contains, which acts as a ferment. There can be little doubt that, in the bodies of persons who die of disease, a process of decomposition goes on constantly in the liver after death, although for some time it may produce no striking change. In animals that were killed, M. Bernard (see page 55) constantly found sugar in the liver, when the liver was analyzed immediately after death; but, if some hours only were allowed to elapse before the analysis was made, no sugar was found. In this short time, the sugar had been changed into some other substance.

We may expect, then, most frequently, to find the bile acid when it is unnaturally pale, or contains a large proportion of unhealthy mucus, and is thus unnaturally prone to decomposition; when death occurs from exhaustion, and rapid decomposition of the body ensues; and when the body is examined a considerable time after death, in hot weather.

We may expect, also, sometimes to find it acid in those cases of jaundice from suppressed secretion, in which the unexpected occurrence of fatal head-symptoms, the softened state of the liver after death, and the early putrefaction of the body, evince the existence of some noxious agent which seems (see page 262) to be developed in the system by decomposition of the broken-up hepatic cells, or of the retained elements of the bile.

In some instances, the bile may be rendered acid, as Gorup-Besanez has suggested, by the presence of pus, generating lactic acid. It is possible, however, that, under certain circumstances, bile may be acid when first secreted.

Dr. Prout seems to have imagined that, in consequence of great development of lactic acid, either in the stomach from imperfect digestion, or in the blood from constitutional diseases, especially those produced by malaria, the portal blood might become black and acid; and that this unnatural blood passing through the liver might disorder its secretion, and the bile might thus be deprived of its neutralizing properties, "if not actually rendered acid." I am not aware that any attempts have been made, by chemical analysis, to settle this important point.

Urea has been found in the bile, only, I believe, in persons dead of cholera. It was first detected by Dr. O'Shaughnessey in bile which he analyzed at the request of Dr. Roupell, and which was

1 See Prout on Stomach and Urinary Diseases, 3d edition, Introduction, p. 45.

taken from a person who died of cholera, after having made very little urine for eight days. The bile did not differ in appearance from ordinary bile, but contained, in one thousand parts, six of salts, and three of urea.-(Roupell on Cholera, p. 84.)

Various medicines have been found in the bile, but our list of those which pass off in this way is, doubtless, very imperfect. It is probable that most of the medicines which increase the secretion of bile pass off, in part, either bodily or more or less changed, through this channel.

The observations made by chemical analysis on the altered qualities of the natural constituents of bile are very few, and of little value. They are sufficient to show that some of the natural constituents of bile become changed in disease, which might have been anticipated from the readiness with which the principles of bile enter into new combinations; but they do not tell us in what these changes consist.

The difficulty of analyzing bile, and the circumstance that human bile can only be obtained in small quantity, and many hours after death, when the bile in the gall-bladder is probably already changed by decomposition, sufficiently account for the observations of this kind yet made being so few, and so little to be relied on.

The most valuable observations that have been made on altered qualities of the bile-and these are few and imperfect-relate to changes that can be at once recognized by the senses.

In some cases, the coloring matter is deficient, the bile found even in the gall-bladder is pale and thin, and has not its usual bitterness, and the lining membrane of the gall-bladder and gall-ducts is hardly stained by it. This condition of the bile is frequently found in those diseases which change the structure of the whole liver. It is not uncommon in cirrhosis; and is now and then remarked where the liver is much enlarged from the interstitial deposit of fat, or other morbid products.

But occasionally the bile has these characters when there is no apparent disease of the liver itself, and when the unnatural quality of the bile results from an unhealthy state of the blood. I have several times found bile of this kind in persons dead of granular kidney; and in two cases of suppurative phlebitis, with scattered abscesses in the lungs and other parts of the body, without there being any abscess or other marks of inflammation of the liver.

The elaborate researches of M. Louis have shown that, in persons

dead of typhoid fever, the bile in the gall-bladder is often (in more than one-half the cases) more thin and watery than healthy bile, and often, in consequence probably of oxidation of the coloring matter, has a reddish or rust color, instead of the yellow or greenish tints proper to bile. It has been remarked in a former chapter that, in typhoid fever, suppurative inflammation of the gall-bladder sometimes comes on, doubtless in consequence of the retention, and it may be the decomposition, of unhealthy and irritating bile.

The observations of M. Louis, on the condition of the cystic bile in persons dead of typhoid fever, have been confirmed by the late researches of Gorup-Besanez, who states that he analyzed many specimens of bile taken from the gall-bladders of persons who died of this disease, and found that not one of them contained more than half the usual quantity of solid matter.

In persons dead of inflammation of the lungs, according to GorupBesanez, the bile in the gall-bladder has often the outward characters so common in typhoid fever, and contains an unnaturally small proportion of solid matter.

The same thing not unfrequently happens in dysentery.' But in none of these cases do the color and consistence, and the relative proportion of the solid constituents, of the bile in the gall-bladder, afford very trustworthy evidence respecting the characters of the bile when first secreted, because the bile undergoes concentration in the gall-bladder, and consequently its color and consistence depend very much on the time it had been in the bladder when death occurred.

In other cases, and sometimes even in the diseases referred to above, the bile, instead of being pale and thin, is unusually darkcolored and thick. This may be from mere concentration in the gall-bladder. If the bile remain long in the bladder, much of its water is absorbed, and it becomes in consequence very dark-colored and viscid. This is usually found to be the case in healthy persons who die from some accident after long fasting. In persons who die during the cold stage of malignant cholera, where the whole body is drained of its water, the bile in the gall-bladder is always of a dark olive, and viscid. In persons who die of phthisis, the bile in the gall-bladder, even when the liver is fatty, is often very dark-colored and viscid; most probably from remaining there long, and becoming concentrated, by reason of the repugnance to food and the consequent

1 See Parkes on Dysentery, &c. p. 46.