stance, supplied by other branches of the vein, may remain uninjured. A portion of the liver is lost, proportionate in amount to the number and size of the obliterated branches of the vein-and the person must suffer all the evils which such a loss entails. The disease, in its effects, is like that form of adhesive inflammation of the substance of the liver which leads to new fibrous tissue in the portal canals of considerable size, and in two of the three instances I have mentioned was attended by marks of disease in the capsule of the liver, and in the spleen, such as are usually found in that affection. In these instances, it was probably brought on by spirit-drinking. Rokitansky is of

opinion that this disease of the liver is in many cases the result of direct communication between the venous system of the liver and that of the body, in consequence of the umbilical vein remaining pervious.

It is probable, from the observations of Mr. Henry Lee, before referred to, that obliteration of branches of the portal vein is sometimes produced, not from inflammation of the vein and the effusion of lymph from its inner surface, but from mere coagulation of the blood within it, caused by the absorption of some noxious matter from the stomach or bowels.

When many branches of the vein are thus obstructed, the impediment to the passage of blood through the liver, as in high degrees of cirrhosis, may cause ascites and slight jaundice, and may lead to great enlargement of the superficial veins of the belly. After a time, the enlargement of the superficial veins may form a sufficiently free channel for the blood to the heart, and the ascites may gradually disappear. In the autumn of 1844, I witnessed, in the Dreadnought, a case which I imagine to have been of this kind. The patient, a sailor, was in the hospital eight years before, for what was supposed to be some affection of the stomach. The symptoms which led to this inference were soon followed by slight jaundice, and by great ascites, for which he was tapped three times in quick succession. The ascites. recurred again, but after a time slowly and gradually disappeared of itself. When I saw him, he had been long free from ascites or jaundice, but had an enormous bunch of large tortuous veins, which emerged from the belly just above the umbilicus, and ran thence up the chest. He told me that he first noticed these veins four years before, after the ascites had disappeared.

It sometimes, though very rarely, happens that the main trunk of the portal vein becomes completely obstructed in the same way. This

usually leads to profuse hemorrhage from the stomach and bowels, the result of the great congestion of their mucous membrane; to great ascites; to deep and persistent jaundice; and to rapid shrinking of the liver. An instance of this, in which, at the end of a month only, the liver was found to be no larger than the two fists of the subject, was published, in 1849, by M. Monneret, in a French periodical (L' Union Médicale, 1849, No. 13); and several other cases of the same kind are on record. Complete obstruction of the trunk of the portal vein soon destroys life, not so much by stopping the office of the liver, as by preventing the return of blood from the intestinal canal.

Inflammation of a branch of the hepatic vein is, as already remarked, occasionally produced by a small abscess in the liver, consequent on phlebitis of some distant part. The abscess, touching the thin coat of the vein, sets up inflammation on its inner surface, just as it sets up inflammation of the peritoneum above it when it reaches the surface of the liver. Lymph is effused within the vein at the point where it is touched by the abscess; the canal of the vein becomes closed at that point; and all the branches that feed it, even back to their capillary divisions, become subsequently, and in consequence, choked with fibrine and coagulated blood. If, as more frequently happens, the abscess cause ulceration of the coats of the vein before its canal is blocked up, a small quantity of the pus oozes into the vein. The pus coagulates the blood, and thus chokes the vein, and also sets up suppurative inflammation of its inner surface. After death, the vein backwards from the ulcerated point is found filled with fibrine and coagulated blood, with here and there a little purulent matter. I have observed these marks of inflammation in a branch of the hepatic vein, in two instances in which small abscesses had formed in the liver after amputation. In a portion of liver sent me by Mr. Busk in November, 1843, which was taken from a man who died of phlebitis after amputation of the thigh, several branches of the hepatic vein were inflamed in this way, and obviously from this cause. The liver contained many abscesses, of the size of peas, and lined by a distinct, but very thin membrane.

Dr. James Russel, of Birmingham, has sent me notes of a case in which the same changes were observed. The patient died in the Birmingham Hospital, in 1836, eighteen days after amputation of the leg.

A somewhat similar case has been published by M. Lambron in the Archives Générales for June, 1842; but here the abscesses in the liver were most probably caused by a cancerous ulcer of the stomach.

From these instances, it is probable that inflammation of one or more branches of the hepatic vein is not uncommon in cases where abscesses form in the liver after injuries of the head or limbs. From want of careful dissection, this disease of the vein must be often overlooked.

Inflammation of the hepatic vein from other causes is, I believe, extremely rare. The only instance in which I have seen evidence of it was in a man who died in King's College Hospital in February, 1844. All the hepatic veins seemed thicker and more opaque than natural, and, on examining them closely, I found a thin false membrane on their inner surface, which in the large veins could be readily stripped off. There was a great deal of new fibrous tissue in all the portal canals of considerable size, and some in the small ones also -enough on the whole to render the liver tough, but not distinctly hob-nailed or granular. The liver and the spleen were united to all the adjacent parts by means of old tissue-and there were some adhesions, apparently of the same date, between adjacent coils of intestine. The pericardium adhered to the heart by means of a thick layer of tough fibrous tissue; and both lungs were everywhere adherent to the pleura costalis. The patient was a tailor, 52 years of age, and for many years had been in the habit of drinking enormous quantities of gin. It was this probably that caused the adhesive inflammation of which so many traces were found.1

There can be little doubt that the adhesive inflammations, of which so many traces are found in bodies examined at our hospitals-cirrhosis, obliterated portal veins, thickened capsule of the spleen, puckering of the surface of the kidney from obliterated vessels, stricture of the pylorus from contracted lymph in the submucous areolar tissue, and, in many cases, adhesions of the pericardium and pleura-are mainly attributable to spirit-drinking. The inflammation which this causes is always adhesive.

SECT. V.-Inflammation of the Gall-Bladder and Gall-DuctsCatarrhal and Suppurative Inflammation-Croupal, or Plastic, Inflammation-Ulcerative Inflammation-Effects of Ulceration of the Gall-Bladder and Gall-Ducts-Effects of Permanent Closure of the Cystic and Common Ducts-Fatty Degeneration of the Coats of the Gall-Bladder.

THE inflammatory diseases of the gall-bladder and gall-ducts, although of frequent occurrence, have been but little studied, and at present we have not materials for anything like a complete history of them. This is to be ascribed, in part, to the ambiguous character of the symptoms of all diseases of the liver; in part, to the small size of the gall-ducts, which causes them to be often overlooked in dissection. It should ever be borne in mind that the ducts, though small, are very important, from being the only outlets for the bile secreted in those portions of the liver to which they lead. Permanent closure of the cystic duct entirely destroys the office of the gall-bladder of the common duct, the office of the liver itself.

Inflammation of the gall-bladder and gall-ducts probably arises from various causes, each of which determines in great measure the character and course of the inflammation, and its mode of termination-so that we cannot expect a satisfactory account of the different kinds of inflammation until we can arrange them according to the agencies by which they are respectively produced. To attempt such an arrangement at present, would be premature. We must be satisfied with what seems the nearest approach to it: ment based on the appearances found after death. The different forms of inflammation of a mucous membrane, considered with reference to their effects, are:

viz., an arrange

1. What may be called catarrhal inflammation, which merely increases the quantity and changes the quality of the natural mucus, often rendering it viscid, whitish, and opaque. This form of inflammation seems to correspond in degree with the adhesive inflammation of other textures, but it is not adhesive, in the sense before given to that word, because, by a wise provision, the matter poured out on the free surface of a mucous membrane very rarely becomes organized, or permanently adherent to the membrane.

2. Suppurative inflammation, where the matter secreted is purulent.

3. Croupal, or plastic, inflammation, where the matter effused forms a solid, albuminous layer on the diseased surface, of which, when this is a tube, it becomes a cast.

4. Ulcerative inflammation-if, indeed, the process which leads to ulceration can with propriety be classed with those leading to the results before mentioned, and be comprehended with them under the generic term inflammation.

All these different forms of inflammation have been observed in the mucous membrane lining the gall-bladder and gall-ducts, but not with equal frequency in its different parts. Inflammation seldom produces changes sufficient to attract notice in the hepatic duct, or in the branches that go to form it. The coats of the gall-bladder, and of the cystic and common ducts, are not unfrequently found ulcerated, or much thickened and otherwise changed in texture; but such changes are hardly ever met with, in man, in branches of the hepatic duct. It might have been anticipated that the gall-bladder, and the cystic and common ducts, would be more liable to inflammation than the branches of the hepatic duct. They are much more liable to be inflamed by irritating secretions, for the bile always becomes more concentrated, and, if unhealthy, more irritating, in the gall-bladder, and it occasionally becomes decomposed there, giving rise to the formation of irritating products; they are also much more liable to disease from the mechanical irritation of gall-stones, which are usually formed in the gall-bladder; and they are, besides, from their situation, liable to be involved in diseases of adjacent organs. For these reasons, it is, perhaps, best to consider the diseases of the gall-bladder, and of the different portions of the ducts, separately, as far as this can be done.

Catarrhal inflammation of the gall-ducts is, probably, not uncommon. It is not a fatal disease, and, like catarrhal inflammation of other mucous membranes, may cause no permanent changes; so that

I When bile undergoes spontaneous decomposition exposed to the air, oxalic acid is one of the ultimate products, as it is of many other animal substances. Some time ago, Mr. L. S. Beale showed me, in a specimen of ox-bile in an advanced stage of decomposition, a great number of octahedral crystals of oxalate of lime, exactly like the crystals of this substance which are so commonly found in urine.