frequently, as the accumulation tends to recur. Care should be taken before tapping to exclude a distended bladder. The skin having been scrupulously sterilized, the puncture should be made with a straight trocar, in the median line midway between the symphysis and the navel, provided that previous percussion has not revealed an intestinal coil lying directly under the site of puncture. When the fluid ceases to flow the trocar is to be withdrawn, the opening being closed by a suture over which is applied an antiseptic pad. A tight many-tailed bandage applied during the tapping will facilitate the flow, and after the trocar is withdrawn will yield support to the relaxed abdominal wall; this application should never be omitted. The dangers of tapping are syncope, perforation of the intestine, infection of the peritoneum with unclean instruments, and hemorrhage from puncture of an artery of the abdominal wall.

5. DISEASES OF THE LIVER.

FUNCTIONAL DISTURBANCES OF THE LIVER. To appreciate the various symptoms caused by functional disturbances of the liver it is necessary to consider the normal functions of the liver, and to see what symptoms will necessarily arise from the perversion of each function.

1. From disturbed glycogenic function the bodily heat is lowered, so that the patient becomes susceptible to cold; glucose may pass the liver unchanged and may appear in the urine (glycosuria).

2. Destructive metamorphosis of albuminoid matter not being properly performed, uric acid and sub-oxidized urea compounds are retained in the body, giving rise to headache, vertigo, mental dulness, and despondency. Muscular

or articular pains are common. The kidneys may become irritated by the uric acid and the oxalate of lime, and a chronic nephritis may develop. In some cases renal calculi result.

3. Defects in the quantity or the quality of the bile allow of general malnutrition. Fats not being easily absorbed, the patient becomes thin. There are constipation and intestinal flatulence.

4. From the failure of the liver to destroy the poisons arising in the normal processes of digestion (peptotoxines), or the alkaloids of intestinal fermentation, these toxic products pass the liver unchanged, and a general toxæmia is the result.

Etiology.-Functional disturbance of the liver may be primary or secondary.

Primary cases arise-(1) From errors in diet. The food may be too rich, too excessive, or too abundant in fatty and saccharine ingredients, or there may be an over-indulgence in malt liquors. (2) From want of exercise and from deficient oxidation-processes.

Secondary cases arise-(1) From structural changes in the liver. (2) From disorders of gastric or intestinal digestion. (3) From disorders of the heart and the lungs, interfering with a proper circulation of blood within the liver. and with oxidation-processes. (4) Some cases seem to be due to mild malarial poisoning.

Symptoms. Individual symptoms may be inferred from the consideration of the preceding paragraphs. Clinically the cases may be divided into two groups:

I. The whole nutrition of the patient is below par; he looks anæmic and imperfectly nourished, and the complexion has a muddy, sallow tinge. The tongue is furred and flabby. The appetite is generally lost, especially during the earlier portions of the day. The bowels are con

stipated, the stools being dryish and clay-colored. There is a disagreeable taste in the mouth, especially in the morning, variously described as "bitter" or "pappy." The breath is usually offensive. Headaches are frequent; they may be so persistent and severe as to suggest organic disease. of the brain. Attacks of "sick headache" incapacitate the patient from time to time. The mental condition is one of apathy, with periods of irritability and depression. The urine generally shows deposits of urates, of oxalate of lime, or of uric acid. These patients are commonly described as "bilious."

2. Patients of the second group of cases do not become emaciated nor do they lose strength. The intestinal symptoms are slight, but the cerebral symptoms are prominent and distressing. Vertigo is often so pronounced that the patient is afraid to leave the house alone. There is loss of memory, with failure of the mind to concentrate itself for any length of time. Headache is frequent and distressing. There are alternate pallor and flushing of the face, with a sense of throbbing fulness in the head. The urine may contain oxalate of lime, uric acid or the urates, or may be normal. In these cases the symptoms are due to the vasomotor disturbances of the vessels of the brain, due to their irritation by toxic products of body-waste or of intestinal digestion.

The prognosis depends largely upon the will-power of the patient to carry out the necessary treatment.

Treatment.-Any dietetic error should be corrected. The food should be simple and wholesome, and fatty and starchy food should be reduced in quantity. Alcoholic stimulants should, in general, be interdicted. The most benefit is to be derived from active exercise in the open air to the point of moderate fatigue. The exercise, once begun, should be systematic, should be graded to suit the

individual strength of the patient, and should be of such nature as to afford pleasure and enjoyment. The drugtreatment consists chiefly in controlling dyspeptic conditions, in giving laxatives when required, and in the use of cholagogues. Of the latter, podophyllin, rhubarb, ipecac, magnesium sulphate, hydrochloric acid, and salicylic acid are the most serviceable. The modified rhubarb and soda mixture, while unpleasant to the taste, is of great value: R. Pulv. rhei,

Sodii bicarb.,

Pulv. ipecac.,

Tinct. nucis vomicæ,

Aq. menth. pip.,

gr. ij;

gr. v;

gr. 1;

mv;

3j.-M.

Sig. One teaspoonful three times daily, before meals.

CIRCULATORY DISTURBANCES OF THE LIVER. Anæmia. This condition, frequently found post-mortem, is not accompanied by any symptoms.

Active congestion was formerly regarded as a more important condition than at the present time. Physiological congestion occurs after a hearty meal. Acute congestion may occur with infectious diseases, especially malaria, typhoid fever, and dysentery.

The symptoms are not characteristic. There may be slight enlargement of the liver with tenderness on palpation.

Treatment is by active purgation.

Passive congestion (Chronic congestion; Nutmeg liver). -This condition occurs whenever there is a mechanical obstruction to the outflow of blood from the liver, during the course of heart disease with a failing right ventricle, with diseases of the lungs interfering with the flow of blood from the right to the left heart, and with pressure on the vena cava by thoracic tumors.

Pathology. The central vein of each hepatic lobule is dilated, and the liver-cells in its neighborhood become pigmented and atrophied. The cells at the periphery of the acinus become fatty. The mottling of the reddish-brown depressed centre and the yellowish periphery of each acinus gives rise to the term "nutmeg" liver. In long-continued cases connective tissue may be deposited in and between the lobules, starting usually from the central vein. In the earlier stages the liver is enlarged, but the longer the congestion lasts, the smaller and denser the liver tends to become.

The symptoms are chiefly those of the primary lesion with the attending venous congestions. There may be added symptoms of a moderate degree of portal obstruction (see Cirrhosis of the Liver). Nausea, vomiting, and even vomiting of blood may occur, and slight jaundice may be evident in the conjunctivæ and in the urine.

The treatment is that of the original disease. Depletion of blood from the liver is accomplished by vegetable or saline laxatives. An occasional mercurial purgation by calomel or by blue pill is recommended.

DISEASES OF THE CAPSULE OF THE LIVER.

ACUTE PERIHEPATITIS.

Etiology and Synonyms.-The cause of acute perihepatitis may be direct violence, but usually there is found perforation of an ulcer of the stomach or the duodenum, or infection or rupture of a neighboring abscess, especially of the liver, the gall-bladder, or the right kidney. Synonyms: Subphrenic abscess; Subphrenic pyo-pneumothorax.

Pathology. The peritoneum of the liver and of the corresponding surface of the diaphragm is congested and covered with fibrin and pus. Adhesions form, allowing of a