666 DISEASES OF THE LIVER. 



1. Wounds and contusions of the liver; but among sixty cases 

 that he observed himself, or collected from other observers, Sudd found 

 only one case due to injury. 



2. Very similar to the above are the cases induced by impaction 

 of angular concrements in the gall-ducts, but these must be considered 

 as very rare. 



3. Suppurative hepatitis develops more frequently from ulceration 

 or other gangrenous affections of the abdominal organs. It has been 

 found complicating ulcers of the stomach, intestines, and gall-bladder 

 and, in some few cases, abscesses of the liver have been seen to follow 

 operations for hernia or about the rectum. In these cases it is most 

 natural to suspect an embolus of the branches of the portal vein or the 

 transfer of injurious irritating matter to the liver by the portal blood ; 

 but, so far, it has been impossible to obtain any positive proof of this. 

 Budd believes, and most authors agree with him, that the majority of 

 cases of hepatitis of the tropics belong in this class. It is' true that it 

 is very rarely a primary disease, but is almost always secondary to the 

 dysentery endemic in the tropics ; but it has not been proved in this 

 form either, that the transfer of particles of gangrenous mucous mem- 

 brane or of putrid fluid, from the large intestine to the liver, has induced 

 the inflammation in the latter, and still less that this is the sole cause 

 of hepatitis in the tropics. The fact that epidemic dysentery in our 

 country is hardly ever complicated by hepatitis, although with us also 

 there are extensive gangrene of the mucous membrane and putrid de- 

 composition of the contents of the large intestine, rather militates 

 against Budd's view of the subject. 



4. Lastly, among the exciting causes of parenchymatous hepatitis, 

 we must mention injuries, suppurations, thromboses, and inflammations 

 of the veins. The explanation of this form, which, together with the 

 above, is usually called metastatic hepatitis, is very difficult. We 

 have given the views at present prevalent concerning the formation of 

 metastases in the lungs. According to the explanations there given, 

 the occurrence of metastases in the liver from peripheral suppurations 

 should induce the belief that emboli which have passed through the 

 capillaries of the lungs may plug up the hepatic artery. We must 

 content ourselves with having mentioned the fact, and called attention 

 to the difficulty of its explanation. The sympathy between the head 

 and the liver, of which we have already spoken a good deal, can only 

 be explained by the fact that wounds of the skull affecting the diploe 

 very readily induce metastases, and, under some circumstances, metas- 

 tases to the liver. 1 



ANATOMICAL APPEARANCES. In parenchymatous hepatitis, the 

 entire organ is never inflamed, but there are always inflamed spots 



