CONGESTION OF BLOOD IN THE LIVER.

This Mr. A. supposes to be a much more frequent occurrence in this as well as in tropical climates than is imagined. He conceives that it is present in the early stage of the majority of febrile diseases-particularly those which are idiopathic-and that it is not generally overcome until after the stage of excitement has been fully formed. The rationale of this state of hepatic congestion is substantially the same as was given by Dr. Johnson many years ago-namely, the peculiarity of the portal circulation, with reference to the general circulation. Mr. Annesley conceives that this hepatic congestion not only plays an important part in fevers and many other inter-tropical diseases, but leads to hepatic inflammation, the great scourge of Europeans in India.

"We have already alluded to the existence of congestion of the liver, during the progress and decline of other diseases. This is particularly remarkable in the history of the dysenteries of India, and in the remittents, intermittents, and continued fevers of that country, and indeed of other intertropical regions. Even in the dissection of those cases which terminate fatally, whether from fever of whatever type, from dysentery, from cholera, either simple or epidemic, or from disorders of the other abdominal viscera, and even in those more particularly affecting the head or chest, great congestion of the vessels of the liver is not infrequently observed. Nor can the appearance be considered more the consequence of death, or of the changes immediateÎy preceding dissolution, than previously existing disorder; for the attentive observer may often remark the signs usually characterising congestion of the liver, during the life of the patient, or may trace an obvious connexion between this condition of the viscus and the disorder of which the patient died."

The anatomical characters of this congestion of liver are well illustrated by plates, which, from the size and price of the work, are unfortunately beyond the reach of the profession generally. We may shortly state that the viscus is usually much increased in size, particularly the right lobe, and in a direction upwards into that side of the thorax, forming a large segment of a circle. The colour of the organ is generally changed by the congested state of its vessels, and seems to depend on the particular sets of vessels which are the seat of this plethora, and also on the absence or co-existence of accumulations of bile in the ramifications of the hepatic ducts.

"In some cases, the surface of the liver is of a darker brown than natural, almost amounting to black, greenish black, or bottle green, and this deep colour in some instances passes very abruptly into a reddish or light-brown tinge. Sometimes the surface of the congested liver is variously mottled, or marbled, and occasionally it is streaked and clouded, of a yellowish-brown, greenish-black, or yellowish-green hue. These shades of colour are generally more remarkable upon its upper or convex surface, but they are often observed upon the concave surface, and are quite independent of any effects which may have been produced by the bile contained in the gallbladder. Sometimes the surface of the liver is very dark; and yet, upon cutting into its substance, the subjacent texture is of its usual colour.

"When cut into, the substance of the liver is, however, generally darker than usual, and gives out a large quantity of dark fluid blood: but in regard to fluidity, there is much difference, according to the period which has elapsed from the time

of death to that of inspection. In India, where the inspectio cadaveris is usually made a few hours after death, the blood is observed, in cases presenting congestion of the liver, of a fluid or semi-fluid, or thick consistence, and of a very dark colour. The portal vessels and the hepatic veins are the seats of congestion, and it is often difficult to say which of the two sets of vessels presents this appearance to the greater extent, or more frequently; but we believe that the hepatic vein is more generally congested in the greater degree. In many cases, the congestion of the blood-vessels and accumulations of bile in the biliary ducts, although existing to a great extent, are insufficient to account for the very great increase of the size and weight of the liver, showing that these appearances are often connected with augmented size of the viscus, independently of the extent to which they could have increased its bulk, and of any or ganic disease. On some occasions, congestion and accumulation of bile have been considerable, without any very marked augmentation of size; but more generally, congestion of the blood-vessels, particularly when associated with accumulations of bile in the biliary ducts and gall-bladder, gives rise to increased size of the liver; and such increase is often in relation to the extent to which congestion of the blood-vessels and biliary ducts obtains."

The appearances of the bile are various. Sometimes it is pale, deepening, in different subjects, from a straw colour to an orange-and from that down to yellowish green-green-dark bottle green, &c. In the lighter shades the bile is generally most fluid, and vice versa. Upon making slices of the congested liver, the divided mouths of the distended ducts appear rounded or oval, according to the direction of the incision—and, in some instances, small granular or miliary calculi are found in the ducts. In cases presenting the greatest degrees of congestion and biliary turgescence, the viscidity of the bile appeared to our author to have given origin to the formation of these small calculi in the substance of the liver. The cystic bile in these states of congestion, is generally of a green colour of various shades and consistencies.

The above morbid appearances are often seen accompanying organic diseases of this viscus.

The symptoms which denote, in the living body, these congested states of the biliary vessels, cannot be individually depended on. They must be viewed in connexion.

"When, however, the countenance is pale, anxious, inexpressive, sallow, of a dark or muddy hue; when the tongue is covered with whitish or yellowish-white fur, or otherwise loaded; when the bowels are costive, or when the stools are morbid, dark, and watery, with griping and tenesmus; when the digestion is difficult, attended with nausea, or when the appetite is diminished, and the patient complains of pain and oppression at the scrobiculus cordis, particularly after a meal, with flatulence, borborygmi, and oppressed breathing, and a difficulty of filling the lungs to their utmost; when the skin is cool, clammy, and foul, or of a dark muddy tinge, with irregular chills, sometimes approaching to rigors; when pain, fulness, weight, and oppression, are experienced in the region of the liver, and at the epigastrium, or across the shoul der-blades, or beneath the scapula, and have supervened suddenly; when the uneasiness in those situations is increased upon a full pressure and full inspiration; when the pulse is full, slow, and irregular, or when it is quick, but oppressed; when there is headach, restlessness, disturbed sleep, with unpleasant dreams; and when the urine is turbid, or presenting a muddy sediment,-we may infer that congestion of the vessels of the liver is actually present."

It must be remembered that all, or even the majority of these symptoms are not to be expected in the same individual, although many of them may

be recognised in different grades. The state of the pulse is very variable, and not to be depended on. Mr. Annesley thinks that, although pain, oppression, weight about the epigastrium, or under the scapula, characterise, in general, inflammation of the substance of the liver, yet that these are often marks of congestion also-especially when they supervene suddenly, and are attended with many of the symptoms already described. Inflammation does not arise or reach its acmé in a few hours, but congestion may. Neither can pain, he thinks, be always considered indicative of inflammation, since the membranes of the liver are put on the stretch by congestion. The causes of this congestive condition of the biliary organ are those which have been already portrayed-high atmospheric temperature-too much animal food--too highly seasoned dishes-" indolence and insufficient exercise in the open air"-inordinate use of spirituous liquors.

TORPOR OF THE LIVER.

We were rather surprised to find this section rise in view, after the brilliant doctrine of increased secretion of bile on carbonic acid principles. The torpid condition of this apparatus, however, could hardly have escaped the notice of Mr. Annesley, though both he and his hypothesis manufacturer appears sadly at a loss to account for the phenomenon. After a great deal of physiological and pathological speculation, the meaning of which is far beyond our comprehension, we come to the pith of the business, in the following short passage:

"Torpor of the liver, then, may arise simply from a diminished or exhausted energy of the secreting functions of the organ; and, from this state, complicated with accumulations of bile in the biliary ducts and gall bladder, and with congestion in the blood-vessels of the organ; the former state of disorder gradually superinducing, and becoming complicated with, the latter derangements."

Torpor of the liver, Mr. A. observes, is generally complicated with dyspepsia" and not unfrequently originates in that disorder." As the increase of the secretion was accounted for by the diminished production of carbonic acid gas in the lungs, we wonder that Mr. A. and Dr. Copland did not try to connect the diseased secretion with some modification of the same doctrine. Instead of the carbonic theory, the following explanation is given, which indicates that the doctrine of sympathy was not entirely annihilated in their minds :

"Over-excitement, also, of the perspiratory functions, from long-continued marches, fatiguing exercises, and too warm clothing, is not unfrequently productive of considerable exhaustion of the secreting actions of the liver, and often disposes it to torpor, venous congestion, and accumulations of bile in the biliary ducts, upon the slightest exposure to cold, to moisture, to the impression of malaria, and when the depressing passions are brought into operation, or when hurtful or indigestible matters are taken into the stomach."

Whether those exposures to cold, moisture, malaria, &c. do not influence the cutaneous secretion, we leave to our readers to determine. The symptoms indicative of this torpid state of the biliary organ are next delineated. It is acknowledged that these symptoms are not always so unequivocal as could be wished.

"If, however, we find the patient to complain of want of appetite, drowsiness, with pain over the eyebrows, lowness of spirits and hypochondriacal feelings, dark and high-coloured urine, a costive state of the bowels, and pale or clayey motions, a dark or sallow countenance, wasting of the flesh, slow and painful digestion, with the symptoms noticed in a previous section as constituting diminished function of the stomach, flatulency, particularly of the bowels, without any evident fulness or enlarge. ment in the region of the liver, but with a bitter or disagreeable taste of the mouth, and a loaded state of the tongue, particularly in the morning, we may reasonably infer that the functions of the liver are inadequately performed; but it is by no means so easily to be determined whether or no such torpor is the result merely of diminished function, or of change of the structure of the organ, unless we are acquainted with the patient's habits and the nature of his former ailments. When the foregoing symptoms occur in one addicted to the use of spirituous liquors, or in one who has resided long in a warm climate, and suffered former attacks of hepatic disease, then the latter alternative may be more reasonably inferred."

After detailing a sufficient number of cases illustrative of this torpid state of liver, Mr. A. proceeds to the treatment of these functional disorders of the biliary apparatus. This may be summed up in a very concise manner. Where plethora exists, and the patients have been living too free, blood-letting is recommended, as the first step-and local depletion afterwards, if necessary. The antiphlogistic system should be strictly adopted, and the bowels to be kept well cleared by purgatives. Where sickness and bilious vomitings obtain, warm water is ordered, and afterwards a brisk dose of calomel. Even when all the morbid secretions are cleared away, Mr. A. recommends a full dose of mercurial at night, with aperient draughts in the morning, with a view of changing the secretions of the liver, and effecting a healthy flow of bile. If the mouth becomes affected, under this treatment, a healthy state of function of the liver is the more likely to supervene speedily." It is not the object, however, of Mr. A. to affect the mouth by mercury. In many cases, where the rush of vitiated bile into the duodenum occasions distressing symptoms, cordials will be necessary before the purgative plan is put in force. In respect to that form of disorder, which has been termed torpor of the liver, Mr. A. found a full dose of calomel at bed time, followed by a bitter aperient medicine in the morning, the most beneficial practice, with blisters over the epigastric or hypochondriac regions. After a few days of this treatment, the pilula hydrargyri combined with the pil. alois. cum myrrha, is prescribed at night, with the bitter aperient in the morning. The practitioner is warned against the exhibition of tonics and stimulants for the apparent debility which accompanies these biliary derangements.

This carries us through full half of this immense volume, and to the end

of functional disorders of the biliary apparatus. In another article we hope to afford our readers a general view of the remaining chapters dedicated to inflammation and to various organic diseases of the liver. We shall withhold any general observations on the work till the close of our analysis, hoping by that time to enable every reader to judge for himself. We cannot help, however, again expressing our regret, that the letter-press of this volume should have been so very much expanded by disquisitions that might have been spared, and by didactic precepts far too much spun out. It is probable, indeed, that the talented author may think it much better to be needlessly minute than unsatisfactorily brief. On this point he may be right and we may be wrong..

XVI.

An Essay on Diseases of the Jaws, and their Treatment; with Observations on the Amputation of a Part or Whole of the Inferior Maxilla, &c. By LEONARD KOECKER, Surgeon-Dentist, Doctor in Medicine and Surgery, &c. &c. 8vo. pp. 95. London, 1828.

THE author of this little Essay is a very ingenious and scientific dentist-a regular graduate of medicine and surgery, and therefore more acquainted with medical science generally than most of the professors of dental surgery. That this extended acquaintance with the structure, functions, laws, and diseases of the human frame has not tended to make him the less a good dentist, we have the very best means of knowing—and a long and successful practice of this branch of his art in America, where diseases of the teeth and neighbouring parts are still more prevalent than here, has afforded him the most ample means of studying all the minutiae of dental surgery, with the greatest advantage. We can confidently assure our readers, that both the author and his book are worthy of professional patronage, and we hope that patronage will not be withheld because he is a foreigner. As this Essay lies in a small compass, and embraces many interesting points of general as well as special surgery, we recommend it in the original to our readers, and shall only offer a very short analysis of its contents in this place.

In some preliminary remarks, Mr. K. has criticised, with great candour and amenity, certain opinions of Hunter and Fox, respecting diseases of the antrum and maxillary bones. Thus Mr. Hunter, in treating of diseases of the antrum inclines to the opinion, that they originate from an obliteration of the duct leading to the nose; whereas the closure of this duct is the consequence, and not the cause of the antral inflammation.

"His proposed plan of perforating the partition between the antrum and the nose, as well as of opening the inside of the lip, is not only entirely useless in a curative view, but likely to increase the disease; and very probably such treatment would never have been successful, even in the first stage of the disease, had it not been combined with better remedies, which, however, from some unhappy prejudice, or erroneous principle, were considered as secondary means, and seldom adopted until the patient had pre viously been subjected to painful and unnecesssary operations."