:

with oleaginous matters, as butter, lard, &c., died of inanition, although they became remarkably fat: in all, the liver was fatty. 2. In certain wasting diseases; but more especially-nay, almost peculiarly-in Phthisis. According to Louis, this change occurs in about one-third of phthisical patients it is much more frequent in females than in males.* It is not very easy to account for its production. Some have supposed that, in consequence of the office of the lungs being gradually more and more interfered with, the elimination of the hydro-carbonaceous matters (of which fat is the most conspicuous) from the system is effected chiefly by some other organ, and that that organ is the Liver. But to this opinion it has been objected, that in Asthma and other diseases, in which the respiratory functions are very imperfectly performed, we never find the fatty liver; and, on the other hand, that this morbid change is occasionally met with, when the lungs are not at all affected. It has been found in persons who have died from Cancerous disease, from caries, from chronic dysentery,† and other wasting maladies.

The general inference, drawn by our author from these and other facts, is, that in the process of wasting, the fat stored up in the body is largely taken up by the veins, so that it comes to be in excess in the blood, and is then laid hold of by the hepatic cells, which have a natural affinity for it. Fat is, without doubt, secreted in large quantity by the Liver, and by the sebaceous glands, whenever a large quantity of it finds its way into the blood." According to this view, the fatty degeneration of the liver is essentially not more a disease of this viscus, than Diabetes is a disease of the kidneys: these organs only serving to eliminate certain matters already formed within the system.

The "waxy liver" seems to be only a variety of the fatty liver, and need not detain us; and the sole reference that we shall make to the following section on "Scrofulous Enlargement and other kindred states," is to extract the following passage on the treatment of such maladies.

"When the enlargement of the liver is consequent on scrofula, our chief reliance must be on warm clothing; sea-air and bathing; a light nourishing diet, comprising a liberal allowance of animal food and wine; and the preparations of iodine and iron, separate or combined.

"When the health has been broken by the combined effects of syphilis and mercury, warm clothing, a tonic regimen, iodide of potassium, nitric acid, sarsaparilla, and guaiacum, are the appropriate remedies.

tion, which is soluble in the blood, it is acted on by oxygen much more readily than the insoluble fat, which is thus protected, and laid up in the system. Alcohol has a still stronger protecting power, for similar reasons."

Query-Does experience bear out this ingenious reasoning in reference to ardent spirits? Are those people, who are much given to their use, generally fat?

There is often an accumulation of fat about the heart also, in Phthisis. This has been suspected to serve merely as a sort of compensation for the wasting of its muscular tissue; the heart requiring to have a certain amount of fulness and bulk, to admit of its cavities assuming the necessary changes of volume and position in the acts of systole and diastole.

In persons, who have died of chronic Dysentery, we not unfrequently find that the omentum and appendices epiploice are unusually loaded with fat. Cruveilhier alludes to the frequent accumulation of fat about cancerous growths.

"In either case, the original malady is faulty assimilation, and, if we can remedy this, we shall probably, in most cases, if not in all, remedy the unnatural condition of the liver, and other secondary ailments.

"My own experience leads me to think highly of frictions with iodine ointment, long-continued, in such cases. I have several times seen an enlarged liver reduced to its natural volume by iodide of potassium and frictions with iodine, or, simply, by these frictions and saline purgatives. The matter deposited in the liver does not become organised, like the fibrine poured out in inflammation, and, if the general health mends, it may, in time, all pass off in the bile, or be removed by absorption." P. 254.

Dr. Graves has recorded, in his Clinical Medicine, several cases of enormously enlarged liver gradually subsiding under a course of treatment, persevered in, perhaps, from six months to two years.

The Section on Gall-stones is full of interesting matter. These substances are almost always formed at first by a portion of the bile becoming so inspissated as to become solid; around this, as a nucleus-which is usually of a dark olive or black colour-is deposited Cholesterine, mixed with variable quantities of the colouring matters of the bile. They are usually formed in the gall-bladder; but occasionally in the hepatic ducts. The latter variety is generally much darker and more irregular on its surface-in consequence of the absence of any investing deposit of Cholesterine than the ordinary kind. Some gall-stones-especially those which are solitary-are composed almost entirely of this substance (cholesterine), and are then nearly quite white, and of a crystalline appearance: they have a soapy feel, and burn in the flame of a candle with a bright flame. The number of gall-stones may vary from one to as many as two or three thousand.

"Gall-stones are very light, considering their size. When fresh from the gall-bladder, they usually sink, if placed in water. When they have been kept long, and are quite dry, most of them float, until they have imbibed a certain quantity of the water, when they sink slowly. Their specific gravity depends chiefly on the relative proportion of cholesterine and colouring matter. Cholesterine is lighter than water; the colouring matters of bile are heavier. The lightest gall-stones are therefore usually those which contain the largest proportion of cholesterine. The weight of gall-stones, especially when dry, will, of course, vary also with the character of their nuclei." P. 278.

Dr. Prout says that, when the passage of gall-stones is suspected, directions should be given to mix the fæces with water, on the surface of which the stones, if present, will be found floating. But this certainly will not always happen. "Dr. Watson has also recommended the adoption of this method of finding the stones, but he adds, 'I never but once succeeded in thus catching a concretion in the evacuations of a patient, whose symptoms had led me to search for it.'"

The formation of gall-stones appears to be much more frequent in women than in men; in consequence, probably, of their more inactive mode of life. Among men, it is chiefly among those whose pursuits are sedentary that they are met with: hence literary persons, prisoners, and bed-ridden invalids are most frequently the sufferers. Morgagni was of opinion that the causes of gall-stones are, in a great measure, the same as those of urinary calculi; and more recently, Dr. Prout has remarked that a tendency to the formation of gall-stones of cholesterine is frequently

associated with a tendency to lithic acid deposits in the urine. In some cases, indeed, the symptoms of the urinary disturbance are so predominant as to disguise altogether for a time those of the hepatic suffering, so that the true nature of the attack has been mistaken, until perhaps the evacuation of the gall-stones; after which the patient has speedily recovered. The symptoms of the passing of gall-stones through the ducts into the duodenum are well described in the following passage:

"They generally come on suddenly, two or three hours after eating, with severe pain, like that of colic, in the region of the gall-bladder. The pain is not equable. There is a constant, dull, aching pain, which every now and then is interrupted by a paroxysm so excruciating that the patient bends himself double, or rolls about the floor, at the same time pressing his hands firmly against the pit of the stomach, which sometimes eases the pain. These severe paroxysms produced great exhaustion: the pulse becomes slow or weak, the face pallid, and the whole body covered with a cold sweat.

"Together with these symptoms, there is distressing nausea, and frequent vomiting. The matters vomited are very acid, and, as in all cases of repeated vomiting, while the common duct is not closed, are bitter.

"The severity of the symptoms, and the time they last, are of course very variable, depending on the number, and the form, and the size, of the stones that are passing, and on the previous state of the ducts. In some cases, the symptoms cease after an hour or two, or a still shorter time, and generally, suddenly, as the stone escapes into the duodenum,—and the complaint may be taken for mere hepatic colic. In other cases, where the stone is larger, or the passage is less free, or where many stones pass in succession, the symptoms may continue, with intervals of comparative ease, for several days." P. 288.

When the symptoms last long, the patient always becomes more or less jaundiced, and there is in many cases a marked tendency to the invasion of rigors, recurring at irregular intervals: the same thing is often observed in cases of Stricture of the Urethra, or when a renal Calculus descends along the ureter. Although the symptoms attending the passage of gallstones are often most alarming, the case generally terminates favourably. Occasionally, however, it has proved fatal, either from the supervention of ileus, or from the rupture of the gall-bladder or ducts, and the consequent effusion of the bile into the abdominal cavity.

Chapter IV. is devoted to the consideration of Cancer of the Liver, and of Hydatid Tumours.

The first of these morbid growths is of much greater frequency than is commonly supposed. Our author says: "No serious organic disease of the Liver is, in this country-at least among people who have never drunk hard-so frequent as Cancer;" and Cruveilhier has observed-" of all the diseases of the liver, the most frequent and the most severe is, perhaps, the cancerous degeneration in the form of disseminated masses."

In the majority of cases, Cancer of the Liver is consequent upon the existence of cancer in some other part of the body, more especially in the stomach and mamma: in a few instances, indeed, the disease seems to be primarily developed in the hepatic parenchyma.

The greater liability of the liver than of any other organ (the lungs excepted) to be the seat of disseminated cancer as well as of disseminated abscesses, is chiefly attributable to the circumstance of the entire venous

blood of the stomach and intestines having to pass through its substance, and to the consequent risk of various abnormal matters being detained in its capillary vessels. The cells of Pus, of Cancer, and of other morbid degenerations, are thus apt to become arrested in their course; and the result of such arrest must be to give rise to foci of purulent, cancerous, or other disease in different parts of the Hepatic parenchyma. Such being the case, we are at once prepared to expect that, whenever the stomach or any portion of the intestinal canal is affected with Cancer, the liver, ere long, will become the depository of some of the morbid and morbific germs. It is seldom that a single or isolated cancerous growth is found in this viscus. Usually there are scattered through its substance a great number-often hundreds-of round cancerous tumours; some of them so small as to be distinguished with difficulty, others of the size of a bean, or a walnut, or even of an orange.

"Cancerous tumors in the liver, as in other parts, differ much in firmness, vascularity, and colour, in different cases. Sometimes, the tumors are white and fibrous, or, as it is termed, scirrhous; but far more frequently, especially when numerous, they are soft, or medullary. Instances are now and then met with, in which, in the same liver, some tumors are hard, and others soft.

"Soft cancer presents the same varieties in the liver, as in other organs. Most commonly the cancerous mass contains but few vessels, and is pulpy and whitish, or of a greyish-white-presenting that striking resemblance to brain rather softened, which led Laennec to apply to it the term, encephaloid. In other cases, the tumors are extremely vascular, presenting the appearance known as fungus hematodes. In others, again, they are melanotic. Indeed, every variety of cancer, except gelatiniform, or colloid cancer, has been met with in this

organ.

The colour of melanotic tumors of the liver varies, according to the quantity of pigment granules which they contain. In the same liver tumors may sometimes be found of every shade from light brown to black." P. 302.

A liver, which is the seat of numerous masses of Cancer, usually becomes very much enlarged, so that it may reach down considerably below the false ribs, and even down to the brim of the pelvis; and, as its surface is sometimes tuberculated with the cancerous growths, it may then be felt irregular and knobby on examination of the abdomen. In a few rare instances of the disease, the bulk of the viscus is diminished. In many cases of cancer of the liver, there is more or less of Ascitic effusion present; but the quantity of the effusion is very seldom so great as in cirrhosis of this organ. Not unfrequently, the patient is jaundiced at the same time.

"The most significant symptom" (of cancer), says our author, "is enlargement of the liver. When this comes on in the middle period of life, and especially when it is progressive, and when other conditions that may equally give rise to it, are wanting,-when there is no obstacle to the circulation in the chest, when the patient is not consumptive, and when his habits have not been such as to lead us to suspect that he may have cirrhosis,-it affords, of itself, strong presumption of the presence of cancerous tumors. When the liver is of very great size, and its surface can be felt to be nodulous or uneven, there is no longer room for doubt.

"Another symptom which is of very frequent occurrence, and which may help us to distinguish this disease from some others in which the liver is likewise enlarged, is constant pain and tenderness." 326.

Whenever there is good reason to suspect the cancerous nature of an enlargement of the Liver, we should very carefully avoid having recourse to large or repeated doses of mercury: they can do no possible good; and may rapidly exhaust the patient's strength, and aggravate, most probably, at the same time, the local malady.

Hydatid tumours are very frequently found in the Liver; indeed more so in this than in any other organ of the body. Their contents are usually transparent and limpid as water;* but, in some cases, the sac or cyst is filled with a thick matter, having the appearance of glazier's putty or plaster, mixed with fragments of dead hydatids. This matter is found to consist of phosphate of lime, with perhaps the addition of a little carbonate, and an albuminous substance. When there is an Hydatid tumour in the liver, there are frequently similar tumours at the same time either in the Lungs, in the Spleen, or in some part of the Mesentery. In some cases, thousands of hydatids have been found in the abdomen, under the peritoneum, and between the folds of the mesentery. It is often difficult to determine in what part or organ the primary and parent tumour was formed. Dr. Budd seems to regard the Liver as generally the "point de depart;" for he says:—

"The constancy with which hydatid tumors in the liver are associated in one case with hydatid tumors in the lungs only; in another, with hydatid tumors in the spleen, or in the mesentery only, strongly favours the supposition, that a tumor of the liver may, by the escape of germs into a branch of the hepatic or of the portal vein, or into one of the lymphatics, lead to secondary tumors in the lungs, or in the liver itself, or between the folds of mesentery. In such cases, too, there is generally one tumor in the liver, which, from its greater size, from the greater thickness of its coats, and from other marks of age, looks like the parent of the rest. In a large proportion of such cases, this patriarchal-looking tumor presents ulceration, or other marks of disease, on the inner surface of the sac." 354.

There is the objection however to this hypothesis-as our author himself remarks that we must suppose that the hydatidic germ or cell passes backwards, against the current of the blood, in the veins that go to form the vena porta. The chief argument in its favour is the circumstance, that what is apparently the parent cell (judging from its size, and the thickness of its parietes), is generally found in the Liver.

Hydatid tumours, similar to those we find in the human subject, are very common in sheep, and in other herbivorous animals: they have never been discovered in animals of any other class. The Liver is the organ that is most frequently their seat. It has been said, that if one sheep in a flock is affected with them, all the others will become so, more or less. They are especially frequent in wet seasons, and when the sheep are fed in ill

* This fluid is however most irritating to serous membranes, which it may happen to touch; as sometimes takes place by the bursting of a hydatidic cyst, and the effusion of its contents into the peritoneal cavity. The inflammation thus induced may be as rapid and intense, as that occasioned by the bursting of the gall-bladder. Mr. Cæsar Hawkins has related several cases, in which the fluid of hydatid cysts in the mamma and other parts was very irritating, and caused sloughing and fungoid ulceration.

NEW SERIES, NO. IV.-II.

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