enveloped in a closely woven net of vessels, each carrying off its legitimate burden to its proper destination. Nerves also are distributed to the cells, modifying their activities according to the work in hand.

Keeping this little outline of the hepatic structure in mind, let us observe for a moment some of the processes which normally go on there.

The arterial blood brought by the hepatic artery nourishes the tissues of the gland; but for their industries the cells must have the portal blood rich in food products newly obtained from the alimentary tract by the selective power of an infinite number of epithelial cells, and of capillaries which have their origin in the mucous membrane lining its whole extent. We are ready now to pass in review some of the manifold products these same industrious cells are able to obtain from this, to the unaided eye, homogeneous fluid, and to recall to mind some of the transformations they effect.

The ancients attributed to the hepatic gland the one function of excreting the bile. Nearer to our time it was thought to be the chief blood-making organ, and source of animal heat, as well as emunctory for the bile. In our day, thanks to recent research, it has reached a position of vast importance, being credited with carrying on a great number of complex processes, both chemical and vital, among which may be mentioned the transformation of sugar to glycogen by a process of dehydration, and changing the glycogen later into glucose by the action of a ferment produced by the glands; also the destruction as well as the production of blood-corpuscles, and the transformation of the hematine of the dead discs into bilirubin wherewith to give its rich tint to the bile, which is now known to be not merely an excrementitious substance, but one destined to be reabsorbed, in part, at least, to do further service in the economy, after having been poured into the intestine. One of the most important accomplishments attributed to the organ recently, is the power of detaining and modifying certain toxic substances, such as the alkaloids, atropine, morphine, narcotine and others. The existence of this function satisfactorily explains some facts previously not a little puzzling to observers concerning the action of these poisons when administered by different methods; as the more prompt and pronounced effect and the smaller dose necessary when administered hypodermically than by the mouth or rectum. In the first instance they are introduced at once to the general circulation, and in the others they must first be subjected to the modifying and delaying power of the liver, and afterwards be set free with diminished energy to do their work in the system. The hypodermic method of administering remedies then owes

its chief advantages to this power of the hepatic cells over the alkaloids and other toxic medicinal substances; nor is this influence limited to poisons introduced from without, but includes some which are manufactured in the body, such as ptomaines and the products of various morbid processes.

Thus we have a faithful sentinel at the portal of the body, ready to grapple with our foes from within as well as those from without, working unceasingly and often against great odds to secure our immunity from harm.

This gland is also credited with producing urea in common with most of the other organs and tissues of the body, and with making glucose from proteids and fats; with furnishing iron to the blood; and has even been accused, by one experimenter at least, of producing uric acid.

Remembering the intimate relation between the hepatic lobule and the elements in which it lies embedded, and the many agencies capable of setting up disturbances in their interlobular spaces, where, in fact, many of the disorders which eventuate in portal obstruction have their origin, it is easy to comprehend why diseases of this viscus are frequent, and their consequences so disastrous oftentimes.

Whatever increases the blood supply of this organ beyond the normal limit, whatever retards the flow of blood, bile or lymph through it favors obstruction; whatever causes hypertrophy or atrophy of the inter or intra lobular tissue, whatever causes degenerations or new growths of this organ, leads to engorgement of the portal system of vessels and to obstruction. This being the case, and the number of agencies capable of producing these disturbances legion, it seems almost wonderful that a liver can be found through which the fluids flow freely.

Perhaps the most common of these causes is indulgence in luxurious habits of eating and drinking, especially when united to inactive lives. Other very frequent causes are excessive or prolonged use of alcoholic or other stimulating drinks, violent physical exercise or intense mental application soon after meals, by which digestion is delayed, and fermenting, irritating substances sent to the liver instead of properly elaborated material. Gastro-intestinal catarrh and dilatation of the stomach are sure to produce hepatic derangement sooner or later, and in the same way as delayed and imperfect gastro-intestinal digestion from other causes. Malaria and continued high temperature, chronic heart and lung diseases, tumors of the mediastinum and disturbed innervation, direct or reflex, may induce hepatic stasis and its evil consequences. Sudden and even gradual cessation of habitual losses of blood, as when bleeding hemorrhoids or the menses are suppressed, is often followed by portal obstruction, and gout and rheumatism are often complicated by it.

Very few women pass through the critical age without suffering from this disturbance, and many of the distressing symptoms characterizing these cases are referable to it.

There is another cause of this disorder not often mentioned in medical books, but not unfrequently recognized by the observing physician, namely, the influence of tight clothing in exciting and especially in aggravating and perpetuating it when produced by other causes. Through this weak and dangerous habit the movements of the diaphragm are restricted and in some cases almost abolished, thus nullifying one of the most potent aids to the hepatic circulation which is unfavorably influenced by a very small amount of pressure upon the walls of the organ, such, even, as is produced by a thick layer of subcutaneous fat; and the disturbance must be incomparably greater when, by the pressure of tight clothing, the lower part of the thorax is so contracted that the liver cannot retain its normal shape or position. Being strongly compressed laterally its vertical diameter increases so that it extends to a considerable distance below the border of the ribs, and there is formed at the waist line a deep sulcus in the hepatic tissues called the corset groove. This groove sometimes crosses the common and cystic duct, and has been accused among other things of giving rise to gall stones by impeding the outflow of the bile.

Through this restraint upon the movements of the diaphragm, the intestines and pelvic viscera are robbed of their legitimate exercise, and disease invited.

The evil effects of portal obstruction, unfortunately, are not limited to the tract most concerned, but are felt in many departments of the economy, especially in those of general nutrition, the nervous system and the generative tract.

Sooner or later all the results of imperfect oxidation manifest themselves; there is often tendency to accumulation of fat, a common symptom of suboxidation; the skin becomes discolored and imperfect in texture in many cases, the venous system shows signs of being overfilled, and the arterial of being scantily furnished with blood. Various degrees of mental depression and many other annoying symptoms appear, too familiar to the physician to need rehearsal here.

Whenever portal obstruction occurs, the liver becomes enlarged, and if the disturbance continues it may become double its normal size, so numerous and distensible are its vessels. The pressure of the overfilled vessels upon either tends to retard the circulation, which, added to the original trouble, produces an obstacle to the on-flow of the blood coming from the whole digestive tract; so that, in time, that tract becomes greatly engorged. . It is said that this system of vessels is capable, under considera

ble pressure, of accommodating nearly the whole blood of the body, and from a moderate obstruction the abdomen often becomes greatly enlarged.

The pelvic viscera, as a result of their subjacent position, are soon unfavorably influenced.

The vaginal vessels through their anastomoses with the engorged hemorrhoidal veins gradually become overfilled. The muscous membrane, as well as the muscular layer of the vaginal wall, becomes hyperæmic, and in some cases greatly thickened and oedematous. Every gynecologist must have many times met with this condition.

The circulation of the remainder of the generative tract is not at first afflicted as its vessels do not communicate directly with the portal radicals; but after awhile, when the whole vascular system has been influenced by the slow progress of the blood through the portal vessels, these organs also become involved. There is throughout the economy too much venous and too little arterial blood; the whole nutrition suffers in consequence, and the pelvic viscera do not escape the common lot. Borne down by the abnormally heavy abdominal organs, their supports as well as their proper tissues weakened by depraved nutrition they sink low in the pelvis, their changed position still further impeding the venous current.

In these cases the uterus is sometimes found lying directly across the pelvis from accentuation of its normal anteversion favored by easy yielding of its weakened ligaments; sometimes crowded back against the rectum, its rightful place usurped by the invading intestine.

This state of affairs is an admirable preparation for inflammations and their mischievous consequences, for dysmenorrhea, catarrh, degenerative changes, in fact for any and all the disorders to which these organs are subject, the only exception being those of traumatic origin.

Thus cordially invited, disease is not often long in making its appearance, and is not usually easily controlled unless the whole condition is taken into consideration. If, as has been claimed by eminent gynecologists, new growths of the pelvic viscera are favored by imperfect local nutrition, we have an explanation of their frequent occurrence in those suffering from portal obstruction.

A physician prominent in Boston thirty years ago, is said to have stated that he had never met with a case of well marked portal obstruction in the female unaccompanied by disorder of some form of the generative organs, and my experience coincides with his in this respect.

It is not my purpose in this short paper to discuss the treat

ment of hepatic or pelvic diseases, since volumes would be required to contain all that might be written upon the subject; but by means of a few illustrative cases, I will indicate in a general way how the combined disorders have been treated and with what results.

Case I. Mrs. Y.; age, 45. She had been thoroughly healthy during girlhood, married at eighteen, had two children within a few years after marriage, both labors easy and convalescence uneventful in both cases.

She consulted me for terrible headaches from which she had suffered for fifteen years, and which had become more dreadful and frequent recently, sometimes being almost continuous for a week or even more at a time.

She wakes in the morning with pain through the forehead, temples, eyes and vertex, which increases in severity as the day goes on but subsides at evening, and is less terrible during the night. Whenever there is vomiting at the height of the paroxysm, a degree of relief usually follows. There is extreme hyperæsthesia of all the senses, and irritability of temper, the heart's action very slow, 40 per minute, irregular and feeble, and attacks of dyspnoea and swooning sometimes occur when the pain is the most violent.

Appetite ravenous before an attack.

Other symptoms are obstinate constipation of many years' standing, frequent urination day and night, dyspnoea, flatulence, palpitation, leucorrhoea and bearing down in pelvis. Patient is fleshy, face is flushed and skin slightly jaundiced, there are moth patches on the temples, and the eyelids are deeply pigmented brown. Hepatic region very sensitive to pressure, and the abdomen enormously large and pendulous. Lower limbs oedematous with enlarged superficial veins.

Examination of the pelvis showed the cervix uteri close behind the symphysis pubis, the fundus rested against the rectum, the whole organ quite fixed in its abnormal position. The vagina was shortened and puffy, and gave rather a cool sensation to the examining finger as if the circulation was not very brisk. jecting from the recto-vaginal septum was a tumor of the size and shape of a large pear, hard and somewhat nodular, attached by the small end. There were hemorrhoids within the rectum.

The diagnosis was chronic hepatic congestion, and gastrointestinal catarrh with pelvic complications, probably due chiefly to three factors, namely, high living, tight lacing and an aimless, sedentary life. I accordingly advised absolute freedom from pressure about the waist and upper portion of the abdomen, a light, simple diet containing very little meat, avoidance of all alcoholic and other stimulating drinks, active exercise in the