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damaged, may suffer little inconvenience as long as they are placed in favorable circumstances, and observe those rules which such a condition requires; but whenever, from any cause-as a hot climate, gross living, indolent habits, constipation-a more abundant secretion of bile is requisite to purify the blood, the liver is inadequate to its office, and they become bilious and sallow. In the management of such cases, we have two objects to fulfil: first, to enjoin those conditions and rules of life that render a plentiful secretion of bile less needful; and secondly, to endeavor to render the liver itself more active.

The chief conditions to diminish the quantity of matter which the liver is called on to excrete, are, a light diet, with water for drink ; active exercise; early rising; and a cool, or temperate climate. Acids have been supposed to act in the same way, and have been much in repute as a remedy in liver disorders, particularly in India, where, from the circumstances mentioned, a remedy having this mode of action is especially required.

Various medicines seem to fulfil to a certain extent the second object, that of rendering the liver more active, and increasing in this way the secretion of bile. Mercury, iodine, the salts of soda, muriate of ammonia, and taraxacum have undoubtedly an action of this kind. The first and the last of these medicines, especially, have long been in this country the chief resources of the physician in the treatment of chronic hepatic disorders. The marked temporary benefit often resulting from mercury given for this effect has, from the difficulty of distinguishing the various diseases of the liver, and the consequent indiscriminate use of the drug, led to great evils. This medicine was at one time, by English practitioners, given almost indiscriminately, and long persevered in, for disorders of digestion, many of which did not depend on fault of the liver at all, but on local disease of the stomach or intestines, or on faulty assimilation, the result of debility, which the prolonged use of the mercury but too often increased. Of late, these evils have much abated; but still, before the real nature of the disease is ascertained, mercury is often tried in cancer, and other incurable organic diseases of the liver, in which this and other powerful and lowering remedies can only do harm.

Pepper, ginger, and other hot spices, are also supposed, and perhaps justly, to render the liver more active, and increase the secretion of bile. The great relish with which they are eaten by our

countrymen in the East and West Indies gives considerable sanction to this opinion.

Most purgatives, especially rhubarb and senna, have perhaps an effect of the same kind, and may fitly be styled, in the language of our fathers, cholagogues. Many persons have succeeded in warding off bilious attacks to which they had been long subject, by taking habitually before dinner a few grains of rhubarb. A rhubarb pill will often relieve a slight bilious disorder, even before it has purged.

We may suppose these medicines to excite the secretion of the liver, either by virtue of the impression they make on the stomach and duodenum, or by their becoming absorbed in the stomach and intestines, and subsequently excreted by the liver. Spices probably act chiefly in the former way, and excite the secretion and flow of bile, as they do that of saliva, by the impression they make on the mucous membrane adjacent. Mercury, iodine, and other medicines, probably excite the secretion of the liver chiefly, if not solely, by becoming absorbed into the blood, and passing out of the system with the bile.

We have, indeed, little positive evidence in favor of this theory, by regarding the liver merely, because not many analyses of any kind have been made of human bile; and very few attempts have been made to discover different medicines in it.

Autenrieth and Zeller' state that they found mercury in the bile of animals treated by mercurial frictions; and copper, derived probably from cooking utensils and food, has often been detected in human bile and gall-stones. Bouisson states that the coloring principles of madder and some other substances pass off in the bile; a fact which, if established, would lead us to expect that some principles of rhubarb, senna, and taraxacum might pass off in it likewise. Iodine, I believe, has not been found in human bile, but from its escaping so readily as it does in most other secretions, and from its being found in considerable quantity in the liver of the cod and other fish, we may expect to find it in the bile of persons who die while taking it.

Most medicines that act as diuretics are no doubt excreted by the kidneys. Nitre, iodide of potassium, asparagus, and most other medicines of diuretic action, for which we have chemical tests, or which we can detect by our senses. have been found in the urine.

1 Bouisson, p. 14, who takes this fact from Reil's Archiv. fur die Physiologie, vol. viii. p. 252; 1807, 1808. 2 Id. p. 303.

The active principle of squills, our chief expectorant, probably passes off by the lungs, for all the onion tribe, of which squills is one, taint the breath. It would seem, indeed, not only that most medicines that increase the secretion of a gland pass out of the system through it, but, conversely, that nearly everything foreign to its own secretion, that drains off through a gland or mucous membrane, excites its secreting function.'

Medicines that pass off in this way through a gland, not only increase its activity, but may also alter the qualities of the secretion, and act directly on the surfaces over which the secretion passes; and when the secretion is unhealthy or these surfaces are diseased, these latter effects of the medicines may be far more important than the first.

We have examples of this in the efficacy of alkalies in preventing the deposit of lithic gravel in the urine; and in that of the balsams and of various vegetable astringents, in certain diseases of the bladder and urethra. As might have been expected, our knowledge of the effects of different medicines on the qualities of the bile, and on the mucous membrane of the gall-bladder and gall-ducts, is very scanty. We cannot ascertain during life the composition of the bile, and of course cannot tell in what way, or in what degree, our medicines change it. But there are, unquestionably, medicines which do change it. Experience long ago led physicians to infer that if some medicines, as mercury, owe their chief virtue, in hepatic disorders, to their increasing the quantity of the bile, there are others whose chief merit consists in their altering its quality. Alkalies-especially soda-ether, and turpentine, have been supposed to render the bile thinner, and have, on this account, been, at various times, recommended as remedies for gall-stones. Hitherto, it has been impossible to fix the value of medicines of this class. They are given empirically, generally with a vague notion only of what is amiss; and according to the chances of individual experience, or the fashion of the day, are rated at one time much above their worth, and at another time, in effect probably of this very over-estimate, are altogether discarded.

Medicines which alter the urine, or act on the bladder or urethra, have more permanent favor, because, from being always able to collect and analyze the urine, we have better opportunities of fixing their value.

1 On the same principle, undoubtedly, various abnormal matters that find their way into the portal blood cause sudden and copious fluxes of bile.-Cruveilhier has some good remarks on this in his Anatomie Pathologique.

CHAPTER I.

CONGESTION OF THE LIVER.

Congestion of the Liver from impediment to the flow of Blood through the Lungs or Heart-Effects of this-Congestion from other causes -Hemorrhage.

ONE of the simplest morbid conditions of the liver is congestion; in other words, an undue accumulation of blood in the vessels.

Congestion of the liver, as of other organs that have an active function, may arise from various causes, and be, if we may so speak, of different kinds. The simplest kind, and which may therefore be fitly considered first, is that which results from some mechanical impediment to the return of blood through the veins to the heart.

Examples of congestion arising from this cause are most frequently met with in persons with organic disease of the valves on the left side of the heart. In such persons, it often happens that when the circulation becomes much impeded, the liver grows larger, so that 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 size. This enlargement, from what may be termed passive congestion, often takes place, and again subsides, very rapidly, according to the varying conditions of the general circulation.

Enlargement of the liver from passive congestion is, in general, unattended with pain, and the only complaint made by the patient is of a sense of weight or fulness in the right hypochondrium. The turgid state of the capillary vessels in the lobular substance of the liver, and the slowness of the current through them, impede, however, the secretion of bile; so that it often happens that after a few days these symptoms are succeeded by a sallowness of the complexion, which, in some cases, passes into decided jaundice; the jaundice, like the enlargement, soon disappearing when the general circulation is relieved.

In all organs, a state of congestion produces analogous effects. The unnatural fulness of the capillary vessels, and the slowness of the current through them, lessens the activity of the nutritive processes, and causes the organ to do less of its proper work, and do it more slowly. If the brain be congested, the sensations are blunted, volition is less vigorous, and the mental power is diminished; if the lungs be congested, the exhalation of carbonic acid is lessened; if the kidney be congested, the urine is more scanty; if a muscle be kept congested, it soon tires, and only slowly recovers its fatigue.

It is, then, in accordance with a general law, that when the liver is kept in a state of passive congestion, the secretion of bile is diminished. But the jaundice in such cases does not always depend entirely on diminished activity of the secreting cells. The gorged state of the blood vessels causes pressure on the small gall-ducts, and thus impedes the passage of the bile through them. When the liver is examined after death, it frequently contains not only an unusual quantity of blood, but also, as was remarked by Mr. Kiernan, an accumulation of biliary matter in the lobular substance.

This biliary congestion, as Mr. Kiernan termed it, like the gorged state of the blood vessels, of course tends to increase the size of the organ.

Enlargement of the liver must take place in some measure in all cases where the vessels are turgid, but the degree of enlargement will depend on the time the congestion has lasted, and on the previous condition of the organ. The longer the vessels are kept distended, and the more yielding the surrounding tissues, the greater, of course, will be the enlargement. In young persons, and in persons in whom the liver is healthy, and its capsule thin, it will necessarily enlarge much more for a given force of distension, than in persons in opposite circumstances. When, in consequence of an interstitial deposit of lymph, the liver has become unnaturally firm and tough, an impediment to the free passage of the blood from it towards the heart, unless it be long continued, will produce but little increase of its size; but will cause the same, or even greater, pressure on the other elements of its texture, and be as apt, therefore, or even more apt, to cause secondary biliary congestion.

The changes in the appearance and texture of the liver produced by congestion are such as these considerations would lead us to expect. The liver, from the turgid state of its bloodvessels, is more or less enlarged, somewhat more friable than it otherwise would

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