DISEASES OF THE LIVER - subject is as yet beset with difficulties; we are only now beginning to learn from pathological research the meaning of terms which have been in common use, such as "nutmeg-liver," " cirrhosis," ; we have but little knowledge of what changes are due to inflammation, what to depraved nutri tion ; and therefore cannot speak with certainty of the indications which might show that such a change was going forward; as a necessary consequence, we are in great ignorance regarding its functional disorders, because we cannot discriminate the symptoms which portend the commencement of some grave malady from those of transient disorder.
Another difficulty meets us on the very threshold of our inquiry into the diagnosis of its diseases, viz., that it is exceedingly difficult to separate the symptoms due to disorder of the liver from those of other portions of the digestive apparatus. Covered in great measure by the ribs, there are no aus cultatory phenomena to aid our investigation, except on the single question of ita size ; and placed at the very summit of the intestinal canal, and yet below the valve of the pylorus, the state of its secretion cannot be accurately ascer tained, either by examining the feces, or by exciting the act of vomiting. Half the minor ailments of life are attributed by persons unacquainted with medi cine to "biliousness," while the accomplished physician is almost unable to say what it is to be "bilious." Let us hope that the progress of analytical chemistry may ere long throw some light upon this obscurity, and discover some ready means to indicate at least the more marked changes, which we are quite sure the secretion must undergo.
A patient says that he is "bilious ;" what does he mean ? It is quite true that he often applies the term to a variety of states which we know have nothing in common ; but there must be some general type, to which they all, more or less, approximate— there is something which we may rationally call by that name. The symptoms are analogous to those which we have mentioned as characterizing a fit of indigestion, but they are more marked and persistent; and though in many cases first excited by an in discretion in eating or drinking, yet this antecedent may be wanting, and the lasting headache and discomfort cannot be merely the effect of sympathy with disordered stomach; there must be some material in the circulating medium which ought not to be there; and its frequent association with sense of weight in the right hypochondrium, and pain in the right shoulder, war rant the idea that the fault is in the eliminating process of the liver. The stools are often disordered, sometimes paler than
natural, sometimes darker, leading to the belief that the bile is deficient, or perverted. The general notion of biliousness seems to be nausea, loss of appetite, headache, foul tongue, probably thirst, and disordered bowels: hence we find patients in the early of fever, in certain conditions of phthisis, in erratic gout, stage often in the simple functional disorders of stomach and bowels, imagining that this is the explanation of their sensations. In another form of disease the analogy is much more real; we know that delirium tremens, and disorder of the liver, are both brought on by habits of dissipation; and it may be admitted that a patient is not far wrong who calls himself "bilious." while his white, moist, tremulous tongue, shaky hand, and sleepless eye point him out as being on the verge of an attack of delirium a potu. It is more especially that form of the disease which has been designated delirium ebriosorum, the delirium following on a debauch, that is ushered in by a fit of biliousness.
The statement, therefore, of the patient, that he is bilious, or subject to bilious attacks, must first be analyzed, so far as possi ble, to ascertain what are his actual sensations; and from these we attempt to form a judgment whether the liver be really at fault or not. In the history of the case we can seldom trace, with any distinctness, the duration of the illness; because, in this country, at least, attacks of a really acute type are seldom seen, and the sensations in others are not very definite in their relation to this organ. Under all circumstances, the period during which the patient has been conscious of derangement of health, while it may point to some change occurring at the time, cannot be re garded as the necessary commencement of the disease under which he may be laboring.