sating-organ with the Lungs and Skin in the process of decarbonising the blood.

But there is another way in which the Liver tends to maintain the purity of the vital fluid; and to this point we particularly invite the reader's attention, as the explanation bears upon the history of several of the pathological alterations to which the organ is subject, and which we shall afterwards have occasion to bring under his notice.

"It will be remembered that all the blood sent to the stomach and intestines has to pass through this organ, before it can again mix with the venous blood from other parts of the body. Now the blood that has come from the stomach and intestines must necessarily be charged with many impurities, besides those derived from the mere decay of the tissues. Along the extensive mucous tract with which everything we eat or drink is brought in contact, absorption is constantly going on, and various matters must, therefore, enter the portal vessels, not fit by their nature to form blood, or to serve any other purpose in the body. Many of these substances are removed from the blood in its passage through the liver. The discharge of such matters through the liver, when they are in unusual quantity, or of a particular kind, is, no doubt, the primary condition of many biliary disorders." P. 28.

Having discussed the several points connected with the Anatomy and Physiology of the Liver, the author proceeds to describe its various Morbid Conditions. These he has arranged in five chapters; of which, the first treats of Congestion; the second, of Inflammation and its Consequences; the third, of diseases which result from faulty nutrition of the liver, or faulty secretion;" the fourth, of "diseases which result from some growth foreign to the natural structure;" and the fifth, of Jaundice. There is an Appendix, which contains a good account of the "Liver-fluke" in Man, as well as in the Sheep and other graminivorous Animals.

Congestion of the Liver.

The description given by our author of this morbid condition is lucid and instructive as a matter of course, he has drawn largely, for his illustrations of the changes produced by its presence, from the admirable paper of Kiernan in the Philosophical Transactions. The most frequent cause of Hepatic Congestion is the existence of some obstruction to the free return of the venous blood to the right side of the Heart, in consequence of cardiac or pulmonary disease.

"It often happens," says Dr. Budd, "that in such persons, when the circulation is more than commonly impeded, the liver grows larger. Its edge can be felt two or three inches below the false ribs. If the circulation be relieved by bleeding, or by diuretics, or by rest, the liver returns to its former volume. This enlargement of the liver from congestion, often takes place, and again subsides, very rapidly, according to the varying conditions of the general circulation. "In estimating the bulk of the liver, in congestion and other diseases, we must bear in mind, that its natural limits vary with posture and many other circumstances. It descends an inch or two lower when the person under examination is standing or sitting, than when he is lying down; it is lower after inspiration, than after expiration; and it may be pushed down by fluid in the cavity of the pleura, or by bloated, emphysematous lung." P. 41.

The complexion of patients labouring under Congestion of the liver, in

duced by the cause now mentioned, is usually purplish with an admixture of dingy yellow: the blood is not only imperfectly decarbonised, but is also not completely freed from the principles of the biliary secretion. When the congestion continues for a considerable length of time, the proper secretory apparatus (the nucleated cells) of the liver seems to be more and more injured, until perhaps it is irretrievably damaged; and then the secretion of the bile ceases almost entirely to be effected. Several cases are related by Dr. Budd, "where, from the flow of bile having been long obstructed by the closure of the ductus choledochus, the liver had entirely lost its lobular appearance and contained no nucleated cells; so that, when a portion of it was examined under the microscope, nothing was seen but free oil-globules and irregular particles of greenish or yellow biliary matter." The same effect may probably arise from any serious lesion of the extreme vessels or biliary tubules; as, for example, in the hardened and granular state of the liver so frequent in drunkards, to which the appellation of cirrhosis has been applied.

Besides the mechanical and chronic causes of Congestion of the liver, to which we have alluded, this viscus is liable to become engorged from some of a more active and vital nature. In ague for example, the liver, like the spleen, is apt to be very much enlarged from sanguineous accumulation, during the continuance of the febrile paroxysm. In purpura also, and indeed in most diseases in which the blood is in a dissolved state, hepatic congestion is liable to occur. We need scarcely say that the nature of such congestions, as well as the proper method of relieving them, must be very different from that morbid condition which is induced by a stagnation of the blood in the parenchyma of the liver from organic disease of the heart and lungs.

From Congestion we pass on to Inflammation of the Liver. The character and features of this morbid condition vary very much, according to the exciting cause of the disease, the parts of the hepatic structure that are chiefly affected, and the nature of the patient's constitution. Dr. Budd arranges the inflammatory diseases of the liver under five heads :1. Suppurative inflammation; 2. Gangrenous inflammation; 3. Adhesive inflammation; 4. Inflammation of the veins; and 5. Inflammation of the gall-bladder and ducts. It might be very easy to object to such a classification, which is founded, it will be observed, on two distinct principles-the nature of the morbid action, and its particular locality or seat. The only change, however, which we shall make, is to put the third species enumerated in the place of the first.

Adhesive Inflammation of the Liver :-or inflammation attended with the effusion of Coagulable Lymph. This effusion may be either on the surface, or in the parenchymatous substance, of the organ; but it is more particularly to the latter of these states that we wish to call the reader's attention. The following description of the effects of this lesion-so frequently induced by the use of spirituous liquors-deserves his notice. "Deep-seated adhesive inflammation of the liver produces different effects, according to the parts it principally involves. Sometimes the lymph is effused almost exclusively into the areolar tissue in the portal canals of considerable size,

and if the person die long after this has occurred, all the considerable branches of the portal vein are found surrounded, in some places to a distance perhaps of half an inch, by new fibrous tissue, which by its contraction has drawn in and puckered the adjacent portions of liver. The remaining portions of liver may be little, if at all, altered in texture, and may be readily scraped away from these indurated portions. The main branches of the vein are pervious, but many of the small twigs that spring from them are obliterated. The parts which these twigs supplied are atrophied, and the liver proportionally reduced in bulk. Where such portions are near the surface, the capsule is somewhat drawn in and puckered. Together with these changes, there are usually, if not always, thick false membranes on the capsule of the liver, or extensive adhesion, by means of old tissue, between the liver and adjacent organs. Usually, too, there are old false membranes on the surface of the spleen, and marks of adhesive inflammation of other parts, especially the pericardium and the pleura.

"I have several times met with this form of disease in persons who had drunk hard of spirits. It comes on with well-marked symptoms of inflammation of the liver, pain in the side, vomiting, fever, and perhaps jaundice. These symptoms subside after a time, but the patient does not regain his former health. The liver has been permanently damaged; part of its secreting substance becomes atrophied from closure of the small portal veins, and it is no longer adequate to its office. The patient has difficult digestion, looks sallow, and does not recover his former strength." P. 108.

The deposition of Lymph or fibrous tissue around the smaller branches of the vena portæ, that separate the lobules of the liver from each other, renders its parenchymatous substance much tougher and more indurated than in health. When we make a slice of it, we observe thin fibrous lines interposed between small irregular masses of the lobules. At those parts on the surface of the viscus, which correspond to these lines, its investing capsular membrane is puckered cr drawn in; producing that "hob-nailed" appearance that has been of late so much spoken of.

"The tissue of the liver is paler than natural, from the presence of this white fibrous tissue, and from its containing but a small quantity of blood; and it is often yellowish from accumulation of biliary matter in the cells. When this is the case, a section has the greyish and yellow colour of impure bees-wax, and, in consequence, the disease has been called by the French, cirrhosis—from pgos, yellowish.

"In other cases again, the quantity of this adventitious fibrous tissue is much greater, and by its contraction the lobular substance of the liver is drawn into round nodules, which being of a deep yellow colour from accumulation of biliary matter, are in strong contrast with the gray fibrous tissue between them.

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"This state has been described by Abercrombie, who says, the yellow matter of cirrhosis is sometimes in small nodules, like peas, dispersed through the substance of the liver. He adds, A case is described by Clossy, in which the structure of the liver was wholly constituted of a congeries of little firm globules, like the vitellarium of a laying hen; it occurred in a boy of fifteen, who had immense ascites. In a case by Boisment, these nodules were as large as peas, and the liver was much diminished in size; the case was chronic with ascites. The French writers have a controversy whether the cirrhosis or yellow degeneration of the liver be a new formation, or a hypertrophia of the yellow substance, which they suppose to constitute a part of the structure of the liver in its healthy state. No good can arise from such discussions, as it is impossible to decide them.' (Diseases of the Stomach, &c., 2nd edition, p. 369.)" P. 109.

In the early stage of Cirrhosis, (the gin-drinkers' liver of English writers) the size of the viscus is usually enlarged, in consequence of the deposition

The thinner and more

of serum and lymph throughout its substance. watery part of the effusion is, however, gradually absorbed in time, the fibrine contracts, the small twigs of the portal veins, and their accompanying biliary tubules, are compressed by the new tissue, and the lobular substance of the liver, receiving less blood than it should do, wastes. On all these accounts the liver diminishes in size; and in protracted cases, from the small quantity of blood it contains, and the great atrophy of the lobular substance, it is usually very much smaller than in health.

As, in Hepatitis arising from the excessive use of ardent spirits, the physical and material cause of the inflammation is conveyed directly by the portal vein to the parenchyma of the liver, we are at once prepared to expect that the morbid change should be most conspicuous in it: the capsule or investing membrane is only secondarily affected.* Even in some cases

of "hob-nail" liver, the peritoneal coat remains sound, and the tunica propria is so little, if at all, altered, that it may be readily detached and stripped off. But this exemption from morbid change is certainly not very

common.

Associated with Cirrhosis of the Liver, we not unfrequently find more or less serious organic Disease of the Heart. M. Becquerel-in an elaborate paper upon the subject, published in the Archives Generales for 1840 -states that the heart was diseased in twenty-one out of forty-two cases of Cirrhosis, of which he has given an analysis: he is of opinion that in these cases the heart was diseased before the liver. We think that Dr. Budd is quite justified in withholding his assent to this position, and in maintaining that" obstructed circulation through the chest has no direct influence in causing the disease (cirrhosis), and that it contributes to it only by giving greater effect to the influence of alcohol and other efficient

causes."

The pernicious influence of spirit-drinking in inducing liver-disease is much promoted by exposure to the vicissitudes of the weather-the prolific cause of so many insidious inflammatory affections among the lower classes-by a residence in a hot climate, and by whatever is calculated to disturb the healthy function of the chylopoietic organs, and to vitiate the products of digestion. In a good many of the published cases of Cirrhosis, organic affection of the stomach was present.

It is scarcely necessary here to allude to the symptoms of Adhesive Inflammation of the Liver, and of its consequences; more especially as they vary so much according to the acuteness of the attack, and the stage or period of its existence. The presence of pain and tenderness over the region of the liver, in a spirit drinker, should always be viewed with suspicion, and carefully watched. When the organ has become seriously diseased, the complexion is always more or less jaundiced, and the skin is dry and rough. There is moreover in the majority of cases a tendency to Ascites, and not unfrequently also to various Hæmorrhagic phenomena,

Dr. Percy of Birmingham has stated in his prize Essay, published a few years ago, that, in dogs poisoned by alcohol, he could recover the spirit from the blood, he brain, and various other organs, but in greatest quantity from the liver.

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as bleeding from the nose or rectum (piles are not unfrequent), the appearance of purpuric spots on the surface, and so forth.* There is a circumstance connected with the dropsical effusion arising from this cause that deserves our notice, viz: that the Ascites very often exists alone and without oedema of the legs or of any other part; and that, when there is such œdema present, it almost always takes place subsequent to the Ascites. The cause is obvious; it is the Portal circulation which is at first chiefly, and perhaps only, affected.

Treatment. In the early stage of the disease, when there is pain and tenderness in the hepatic region, cupping over this part, and the use of saline medicines, with low diet, are in general the best remedies. General bloodletting is seldom admissible in hard drinkers: delirium tremens is apt to occur after the loss of much blood. When bleeding is not required, or is not deemed safe, the application of a blister will generally afford decided relief. Dr. Budd says that, when the fever has abated, and the liver is still very large, mercury, and the iodide of potassium, are the medicines from which most benefit may be expected. We would not wait for the abatement of the fever, before we gave the former, at least, of these most potent remedies. A couple of grains of calomel, or three or four of—that excellent preparation-the hydrargyrum cum cretà, either alone or in combination with the extract of colchicum, may be administered night and morning, from the very first setting in of the hepatic uneasiness. Subsequently the Plummer's pill is a most valuable alterative. When ascites has supervened, we must avoid all lowering treatment. Hydragogue cathartics exhaust the strength, without materially diminishing the dropsical effusion; and surely long courses of mercury can do little or no good, when the parenchymatous structure of the Liver is deeply and permanently altered. An occasional warm or tepid bath is always grateful to the patient's feelings, and will often serve to promote the urinary, as well as the cutaneous, excretion. Mild diuretics, with small doses of the iodide of potassium, are sometimes very useful; at least temporarily so.

Suppurative Inflammation of the Liver.

The causes of this serious lesion are various.

1. It may follow a blow or other mechanical injury on the side. Andral has related a case of this sort: but the occurrence is certainly very

rare.

2. A far more frequent cause of Abscess of the Liver is suppurative inflammation of some vein, and the consequent contamination of the blood with pus. It is well known that what have been (not very correctly) called "metastatic abscesses" are apt to occur after injuries, surgical operations, &c., in various internal organs. Of these the Liver is one, in which they very frequently occur more frequently indeed in it than in any other,

* Another symptom is an enlarged or varicose state of the veins on the surface of the abdomen-arising from the impediment to the free return of the blood along the deep-seated vessels. This symptom is often observed in different organic diseases of the abdominal viscera.