Digitized by tine Internet Archive in 2007 with funding from IVIicrosoft Corporation http://www.archive.org/details/clinicaltreatise01freriala Frontispiece. VOLUMK 1 ^^r:y% /■ t .i: •> ) .^ I ^.'^ J ^^.i^fllljlj/j,^ t- ■n ikilnv^^ Kl-M.i;:'-I!s ,,- DISKASKS UF THE LIVER. CLINICAL TREATISE ON DISEASES OF THE LIYER. DK fried: theod. frerichs, PROFESSOB OF CLINICAL MEDICINE IN THE UNIVERSITY OF BERLIN, ETC.; UIDIOAL PRITr-COUNSELLOB AND MEDICAL ADVISER TO THE MINISTRY OF PUBLIC IN&TRnOTIOB AND MEDICINE AT BERLIN. IN THREE VOLUMES. VOL. I. TRANSLATED BY CHARLES MURCHISON, M.D., F.R.C.P., PHYSICIAN TO THE LONDON FEVER HOSPITAL, LECTURER ON PATHOLOGICAL ANATOMY, AND ASSISTANT-PHYSICIAN AT THE MIDDLESEX HOSPITAL. NEW YORK: WM. AVOOD & CO., 27 GREAT JONES STREET. 1ST9. AUTHOR'S PREFACE, With the present Clinical Treatise on Diseases of the Liver, it is intend* ed to commence a series of Works which shall contain the results of my clinical experience and pathological observations. The manner in which I propose to treat the subject, will appear from the works themselves; and it therefore seems needless to discuss this any more in detail at pres- ent; it is only necessary for me to make a few brief explanatory remarks. At the present day, it is agreed, that the science of life is undivided, and that no real defined limits exist between the varying phenomena of health and disease, but that both are governed by the same laws. We endeavor to investigate the conditions under which disease takes place in the same rigidly empirical manner, that we study the general vital pro- cesses of which disease is merely a fragmentary constituent. In addition to simple observation at the bedside of the patient, we have recourse to the assistance of physical, chemical, microscopical, and experimental modes of investigation, in order to collect materials for the construction of a scientific system of medicine. There can be no doubt that a great advance has been made by this mode of research, which, although not novel, has at no time been adopted to the same extent, and with such ample means at our disposal, or attend- ed by equally important results, as during the last ten years. Our gen- eral views of disease have been simplified since we have ceased to discon- nect it from the phenomena of life, as something foreign and endowed with a peculiar and individual existence; while the several pathological processes have been rendered more intelligible, since they have been re- ferred back to their physiological origin, and since their fundamental structural lesions have been carefully and thoroughly examined. The voL ume of the work now presented to the public furnishes ample stores of individual facts, difficult to understand and arrange, and still more diffi- cult to turn to practical account. It is a characteristic of human nature to exhibit partialities, and to elaborate and make use of sometimes one, and sometimes another mode of investigation in preference to any other: *' Suo quisque studio delectatus alterum contemnit; " but no permanent in- jury results from this. iv author's preface. Clinical and practical medicine have made a difficult stand in opposi- tion to the results arrived at by modern means of scientific research. Their representatives, from the very tendency of their studies, have, out of their much-trodden field of observation, been unable to contribute so much as the auxiliary sciences towards the completion of the entire edi- fice of medicine; hence, literature is made up almost exclusively of these auxiliary sciences. The field of actual medical practice has become over- grown by foreign elements, which, owing to the constantly increasing gap between science and practice, have shot up luxuriantly. As at other times of remarkable scientific progress, and as was particularly the case at the commencement of the seventeenth century, so likewise at the pres- ent day, very different views are entertained as to the relations which ought to subsist between scientific and practical medicine. A large proportion of medical men are upholders of the system of prac- tice transmitted from the ancients. They have regard solely to the empir- ical metliod of treatment, and take little cognizance of medical science. They look upon this as something extraneous, from which they select what is practically useful, or what may serve for assisting diagnosis, or for the elucidation of individual symptoms, or some kindred purpose, but their general views are not at all influenced by it. Otlieis again maintain, that clinical studies should have reference solely to scientific medicine, or to some individual department of it, such as pathological anatomv; tliey throw treatment into the background, in- asmuch as the traditional systems of treatment have appeared untenable when subjected to critical examination. Observations in pathological anatomy have l^een misconstrued by such persons, and this, on the one hand, lias led to complete discouragement as to the effects of remedies, aiid to a system of doing nothing, wliilst on tlie other hand, an excess of scientilic acquirements iuis, notwithstanding all the warnings of historv, misled some j^hysiciaiis into the adoption of the so-called rational system of thera]>outics. as tlie only correct system of treatment. In addition to tliese main directions taken by scientific medicine, of whicli there are many varieties, according as the anatomical, the chemical, or the physical side of the question has been most studied and followed out, nitmr'i-ous therapeutic sects have made their appearance, which, re- nouncing all ti-aditional expcrienoe as well as science, have endeavored to eoTistruct systems of treatment of their own. The point of vi.nv in wiiicji tlic subject en clinical research has been considered in the present woi'k is dilfcrent from any yet alluded to. Sci- entific medicine in its entire extent constitutes its groundwork; this paves the way for clinical ooservation v.ithout reference to any practical frsults. .lust as Natural Philosoi/liy and Chemistry did not yield any practi'-a! fiaiits. until these sciences were studied without any regard to innii.'iliate liMivfits to i)e derived from them, so it is with Medicine. Iso- lated pheiioni.-na of disease, or more or less artificial groups of these phe- inomena, do not constitute objects of clinical observation, but the dis- [eased individual himself, in all his aspects; every phase of the varying processes of life, is to be investigated by means of the auxiliaries which natural science has placed at our disposal. The object of clinical medi- cine is to concentrate into one focus the results which are obtained from these various modes of investigation, and to reconcile and perfect the one-sided views resulting from the division of labor. Between the scientific department of clinical medicine, and that of real practice, there exists a chasm, which is bridged over in a doubtful man- ner, at a few places only. It is true, that our treatment at the bedside always becomes more firmly based, the more our insight into morbid pro- cesses is extended; but we are still far from being able to direct it solely by the indications of our pathological knowledge, and precipitation in this matter has always been attended by serious results. The main part of the science of disease is of a purely descriptive character; a scientific interpretation of facts and a clear insight into the intimate connection subsisting between different phenomena, which must precede all attempts at a rational method of cure, having been attained in a few instances only. Hence, treatment is still, as heretofore, handed over, for the most part, to empiricism, but not, however, to that traditional so-called experi- ence, which has no clear knowledge of the subject, which is followed by no certain results, and which does not make any rigid discrimination be- tween the heterogeneous elements which are jumbled together, or between one form of disease and another. Therapeutic researches must be regu- lated in the same manner as pathological. Scientific medicine, although it has not rendered a rational system of treatment possible, has already furnished us with important data in anticipation of such a system. The more careful tracing of the progress of morbid processes, and the insight into their modes of origin and retrogression, enable us to determine the principles of treatment with greater clearness than formerly; a more ac- curate diagnosis secures to us tlie liomogeneous nature of the quantities that we have to deal with, while the study of pharmacy provides us with the first materials for an insight into tlie mode of action of drugs. In treatment, we have not to do with such a novel subject as path- ology, but we have first to prove the correctness, and ascertain the value, of the observations which have been transmitted to us. The materials which scientific medicine at first encountered, resembled in many points the labors of the alchemists in anticipation of modern chemistry. In both cases there were observations which, from being collected with a limited object in view, were consequently defective, and frequently not to be depended on. In the one case there was the idea of the philosophers stone, and in the other there was the supposition of a cure, which an i;nprejudiced and rational interpretation of facts would have entirely dispelled. Medicine ought not, any more than chemistry, to neglect the labors of our forefathers, but must continue to build upon VI the foundation of history. The therapeutic observations of the ancients are in many respects more valuable than the pathological, because treat- ment has to do less vpith the details of local processes than with the exam- ination of the general condition of the body, to which the ancients paid particular attention. These are the principles which I have endeavored to carry out in the present Clinical Treatise on Diseases of the Liver, and which shall also be followed in the subsequent volumes of this series. I know that it is an easier matter to enunciate principles than it always is to remain true to them. Perhaps the will is better than the deed. The diflficulties which surround the pathology of the liver are well known. The minute structure and the physiological functions of this gland are only partially understood, and it is only in recent years that some light has been thrown upon its relations to the metamorphosis of matters within the body. A large proportion of the abnormal conditions of the liver give rise to no marked derangements of the bodily functions obvious to the eye, but they produce alterations in the animal economy, which do not declare themselves in a prominent manner until they have reached a certain height. Hence, in hepatic disease, we do not always expect to meet with accurately-defined symptoms, such as we are wont to observe in affections of the lungs, heart, brain, &G. Where I have enunciated novel views, which as yet it has been im- possible to establish with certainty, as in accounting for icterus in cases where there is no structural lesion of the liver, I solicit a careful exami- nation. I have endeavored to distinguish between statements based upon facts and individual opinion. Experiments in support of my opinions will be appended to the close of the volume. As regards the plan of tlie work, I have in the distribution of my materials, liad anatomy and pliysiology loss in view than medical practice. This explains wliy the subject of icterus is treated at such length; and why I liave annexed to tliis the consideration of acholia and of acute atro- pliy of the liver, which last miglit with more propriety have been consid- eroil under the head of inflammation of the organ. At the end of the worlv, I shall classify the various morbid processes according to their mutual relations. The present volume contains the historical account of diseases of the liver, tlio definition of the dimensions and wciglit of the organ, physical diagnosis, tlie chapters on icterus, acholia, acute and chronic atrophy, the fatty liver, tlio pigment-liver, ' and tlie hvpera^mias and hremorrhages of the livfr. ' Under the head of the pirrmeiit-liver. 1 have been compclJed to expatiate and to describe dia-tnc-einoiits, ■\vhi(:h may bo saiil to have no c^irect connection with hepatic disease. I trust that the rare oiipnrtnnities whieh I have enjoA'ed of observing large accuniiija' ions of jiiymeiit in tlv' blood, and tb.e small number of cases which as yet have been accuratolv described, will be roi'arded as an excu.se for this digression. Vll The more important diseases of the liver will find a place in the second volume : — Inflammation, with its consequences, cirrhosis, the colloid or lardaceous degeneration, morbid growths, the diseases of the bile-ducts and of the portal veins, &c. At the conclusion of the entire work, I pur- pose to collect the general results derived from the isolated data, and to point out their value in reference to the pathology and treatment of the organ. Lastly, I would desire to thank those gentlemen who have aided me in the preparation of this work, and particularly my friends and col- leagues, Herr Reichert, councillor of state, and Professor G. Staedeler of Zurich. I am indebted to the former gentlemen's extensive acquaintance with the entire subject of minute anatomy for repeated suggestions and assistance, while his skill in making preparations has essentially contrib- uted to the success of the Atlas of Plates drawn by Herr Assmann. My friend Staedeler has assisted me on many occasions with chemical advice, and I have to thank him for the elementary analyses of the abnormal pro- ducts of metamorphosis detected in the liver and in the urine. Dr. Valentin has performed a large proportion of the chemical re- searches in my laboratory. Messrs. Professor Riihle, Graetzer, Dr, Hasse, Cohn, and other physicians of All Saints' Hospital have assisted me, by supplying numerous measurements and weights of the viscera, or by calling my attention to interesting cases of disease. To all of them 1 beg to express my warmest thanks. THE AUTHOR. Bbeslau, March^ 1858. TRANSLATOR'S PREFACE. The manner in which the author has treated the subject of " Diseases of the Liver," must be judged of upon its own merits. Many of the facts and views which have been brought forward will be found of much inter- est and novelty to the English reader. There are one or two topics, how- ever, which, since the publication of the German edition of the work, have been the subject of renewed investigations and of considerable dis- cussion, and which therefore demand special notice in this place. The author endeavors to explain certain obscure forms of jaundice, where there is no mechanical obstruction to the excretory ducts of the liver, such for instance, as the jaundice which has been observed in pyaemia, typhus, and after snake bites, on the supposition of an arrested consumption of the biliary acids which have been re-absorbed into the blood, either from the intestine, or directly from the liver. Arguments are bi'ought forward which render it probable, that, even in a state of health, all the bile formed in the liver does not pass into the bile-ducts, but that a portion of it enters the hepatic veins along with the sugar, the quantity which thus enters varying with the distribution of the blood in the gland, and with the relative degrees of pressure exerted by the con- tents of the veins, and of the minute bile-ducts upon the secreting cells, being largest, when the pressure on the sides of the veins is least, and when that on the side of the ducts is greatest. The biliary acids which thus enter the blood, or which are re-absorbed from the intestine, are supposed to undergo certain changes from oxydation, and may thus ac- count for the large quantity of taurine which has been found in the healthy lung, and for the pigments which are naturally voided in the urine. When, however, anything interferes with these normal meta- morphoses in the blood, as when this fluid becomes contaminated hy the purulent infection, or by any other poison, it is supposed that the complete metamorphosis of the colorless bile into urinary pigments is arrested, and that the intermediate substance, bile-pigment, is formed in the blood, so as to color the various tissues and secretions. The arrested metamorphosis of the biliary acids, under such circumstances, is thought to be analogous to the arrested metamorphosis of the sugar formed in the liver, which leads to diabetes. xii teanslator's preface. This view as to the origin of Jaundice Is supported by two experi- ments, tending to show that the colorless biliary acids may become con- verted into bile-pigment. 1. The coloring-matter of bile may be formed artificially out of compounds of the biliary acids with soda. If the glyco- cholate or tauro-cholate of soda be digested for a long time, at an ordi- nary temperature, with concentrated sulphuric acid, the solution gradually assumes several different colors, and after a certain time, on the addition of water, a flaky precipitate, resembling the coloring matter of bile, is pro- duced. 2. Frerichs found that, on injecting ox-bile, entirely freed from its coloring-matter and mucus, into the veins of dogs, the urine afterwards secreted became deeply colored with a substance, which was ascertained on chemical analysis to be bile-pigment. None of the biliary acids in- jected were found in the urine, and, indeed, Frerichs denies that these acids are ever found in the urine along with bile-pigment, although they are sometimes present in urine having no jaundiced hue. From these ex- periments, which were repeatedly confirmed, it has been concluded, that there is an intimate relation between the biliary acids and the bile-pig- ment, and that in fact the former become converted into the latter when subjected to the influence of certain agencies; and it has been thought, that, under certain pathological conditions, the biliary acids normally present in the blood are transformed into bile-pigment. The detailed ac- count of Frerichs' experiments will be found in the section which treats of the Theory of Jaundice, and in the Appendix to the present volume. Since the appearance of Frericlis' work these views, as well as the facts upon wliich they are founded, liave been called in question by Dr. Ktihne ( VtrcJioic^s Archiv, 'ird andAth Part of Vol. JCIV., Sept., 185S); and as an abstract of Kiihne's paper has lately appeared in an English Medi^'al Journal, and may have some influence with English readers (.1/yV///v>^> of Mvdh-lnP, ejlUfdhij Dr. JBe'de, Vo/.I., p. 342, March, 1859), it demands a brief notice liere. Kiilme maintains that biliary acids do constitute an intea'ral part of jaundiced urine, and he attributes the cir- cumstance of their not having been hitherto demonstrated, to the insuffi- ciency of the tests cmjjloyed for tlie purpose. The method which he has fiillow'd lias been tliat of Dr. Felix Hojipe, an account of which will be f('U!!(l in the thirteenth volume of '" ^'irchow's Archives," and in the first voliune of the " Arcliives of .Medicine," edited by Dr. Beale-(p. 344). The following conclusions are arrived at by Ktihne as the result of his invest iij-ju ions. 1. lii jaundice resulting from closure of the. ductus coinmitnis cJiole dci'Ji •:.-', the urine oluyj'js contains l)iliary acid as well as bile-pigment. 2. Tlie jnesenco of biliary acids is a peculiarity of jaundiced urine only. They ai'e never present in normal urine. '.). The biiiai-y acids are not decomposed in the blood. In whatever manner tliey \\\v\ their way into this fluid, they are afterwards excreted unchanged !r>- the kidneys, (ilyco-cholate of soda injected into the veins tkanslator's preface. xiii passes out in the urine unchanged. On the other liand, according to Fre- riohs, when glyco-cholate of soda or any other pure bile-acid salt is thrown into the veins, bile-pigment appears in the urine, while un- changed biliary acids can never be detected. 4. After the injection into the veins of colorless solutions of the biliary acids or of their salts, bile-pigment may appear in the urine, as stated by Frerichs; but the coloring-matter which is developed under such circum- stances is due to the property possessed by the biliary acids of dissolving the blood corpuscles and of thus setting free a quantity of hgematine, which, being acted on in some unexplained way by the biliary acids or their salts, is converted into bile-pigment. In support of this view, Ktlhne appeals to the circumstance of albuminuria or hgematuria having been usually observed after the injection of biliary acids into the blood, and to the following experiment. A solution of haemato-globuline con- taining a minute trace of glyco-cholate of soda was injected into the veins of a dog, and it was found that the urine subsequently secreted gave a splendid reaction of bile-pigment with nitric acid. Ktlhne even thinks it highly probable, that a considerable number of blood-corpuscles are, under ordinary circumstances, destroyed in the liver, and that the coloring matter of bile is derived from the hagmatine set free by the solu- tion of these corpuscles. 5. The bile acids all pass off with the faeces, and are not re-absorbed from the intestine. Quite apart from the correctness of Frerichs' theory of icterus, which, by the way, is only advanced as one that is highly probable, it is obvious that we have here to do with a question of facts, and that Ktihne's facts are diametrically opposed to those brought forward by Frerichs. It is due, however, to Frerichs to state, that the results arrived at by him have been confirmed by several subsequent observers. Dr. Folwarczny, of Vienna {Zeitschrift der kaiserl. konigl. Gesellschaft der Aerzte zi(. Wien. 1859. No. 15, p. 225), examined the urine in three cases of jaundice in Prof. Oppolzer's Clinique, but in all he failed to detect any trace of the biliary acids, although the examination was performed repeatedly, and Hoppe's process adopted in each case. Professor Staedler of Zurich, and Dr. Neukomm, have likewise arrived at results similar to those of Frerichs, and have in Frerichs' opinion, com- pletely refuted the statements made by Kiihne. The results of their re- searches are about to be published (Arc/viv fi'Cr Anatomie, Phys. und WlssenschaftUche Jfed. von Dr. C. B. Reichert und Dr. E. Da Dois Heymond. 1860. Ueher die N^acJnceisimg der Gallen Sauren und die Umirandlung derselhen in der Blutbahn. von Dr. F. N'eiilxomm)', and I am indebted to Professor Frerichs for a manuscript copy of the ^Memoir in which they are embodied. The first portion of this Memoir is devoted to a comparison of the delicacy of the several tests for the biliary acids, Pet- tenkofers, Hoppe's, and that of another recommended by the author. xiv translator's preface. which is a modification of the ordinary process by precipitation with ace- tate of lead. It is shown that the last of these processes is much more delicate than that of Hoppe's. These several processes are then applied to the examination of two specimens of jaundiced urine from the human subject, and to that of the urine of seven dogs into whose blood solutions of the biliary acids had previously been injected. In both the specimens of jaundiced urine, Pettenkofer's test gave a negative result, but the author's process indicated the presence of minute traces of the biliary acids. It is shown, however, that the quantity of these acids was so small (in one instance, only five milligrammes in 1300 cubic centimetres of urine, or less than -^ of a grain troy in 42 fluid ounces) as to bear a very small proportion to the amount which must have entered the blood. Of the seven dogs into whose blood large quantities of the colorless solutions of the biliary acids were injected, in all the urine became colored with bile-pigment within a certain number of hours after the operation; in none could any bitter taste be distinguished in the urine; in none did the urine exhibit the slightest reaction with Pettenkofer's test; and in two cases only did tlie author's test indicate the presence of traces of the biliary acids in this secretion. It is contended that these cases confirm the statements made by Frerichs to the effect that the biliary acids are converted in the blood into 1:)ile-pigmsnt. There would appear to have been some important difference between Kiihiie's experiments and those of Frerichs. Kiihne tells us, that in his experiments the dogs died suddenly, soon after the injection into the veins of tlie colorless biliary acids; whereas it is distinctly stated by Fre- richs that the injection of these substances produced little or no change in the deportment of the animals, and that in one case the experiment was repeated four times without entailing any lasting injury. Moreover, the coexistence of a small quantity of biliary acid along with bile-pigment in jaundiced urine, when it does occur, is not opposed to the correctness of Frericlis' theory, for it may easily be supposed that a portion of the biliary acid may remain unconverted into bile-pigment. As to Kiihne's opinion, tliat the coloring-matter which appears in the urine, after the injection iiito tlie veins of the colorless biliary acids, is derived from the ha?matine of the blood, it may be observed that, although it is possible that the coloring-inatter of the blood may become transformed into bile-pigment, positive proofs are still wanting to show, that such a transformation really takes place. No one has yet succeeded in obtaining bile-pigment from the coloiing-matter of the ]>lood. At all events, Kiihne's experi- ments fail in proving that the coloring-matter in the urine originates from this souriv.^ and not from a transformation of the biliary acids; and they hkev.ise fail in accounting for the disappearance of the biliary acids in- jected into the blood, in any other manner than that suggested by l'"rcrichs. Further observations and experiments on the whole subject are still translator's preface. XV required; but in the meantime it should be understood, that the main facts adduced by Frerichs in support of his theory of Icterus have received confirmation at the hands of most subsequent observers. i Since the publication of the German edition of the first volume, cer- tain experiments have been performed in Frerichs' laboratory by his assistant. Dr. Valentin, which tend to show, that one of the coloring mat- ters of bile consists of haematine, the substance which is known to be derived from blood-pigment. Valentin has succeeded in detecting crystals of haematine in gall-stones, in the bile of men and animals, and in the tissues and secretions of jaundiced patients. The addition of chloroform is found to dissolve the haematine with a yellow color, and from this so- lution red and brownish-red, lancet-shaped, and rhomboidal prismatic crystals separate, which correspond in every respect with those of haematine ( Gilnshurg^s Zeitschrift, Dec, 1858). From these experiments, Frerichs admits there is an intimate relation between bile-pigment and the coloring matter of the blood, and even thinks it probable, that the former substance may be developed from the latter. Still he urges, that no one has suc- ceeded in obtaining bile-pigment from the red matter of the blood, and that Valentin's results are not at all opposed to his theory of the convert- ibility of the colorless biliary acids into bile-pigment. It may be mentioned, that although only the first German edition has as yet been published, most of the corrections and additions for the second edition have, through the kind co-operation of the, author, been incorpo- rated in the present English translation. Unfortunately, the alterations for the section on the " Theory of Jaundice," which have been suggested by the statements of Kiihne, and by the recent observations of Staedeler, Neukomm and Valentin, were not received until long after that portion of the translation had passed through the press. A list of these alterations will be found immediately after the Table of Contents. The German Edition of the work is illustrated by forty-two woodcuts and by an Atlas of twelve colored plates. Twenty-nine of the more im- portant woodcuts have been reproduced by Dr. Westmacott, who has succeeded in improving the style of their execution, without at all inter- fering with the objects they are designed to represent. The republication of the Atlas would have involved too great an outlay, but Messrs. Williams and Norgate, of 16 Henrietta Street, Convent Garden, will supply copies of it to any members of the New Sydenham Society. A few figures rep- resenting the crystalline forms presented by leucine and tyrosine have been copied from the Atlas, and form the frontispiece to this translation. Three other figures (Figs. 30, 31, and 32) have been copied from the same source, and added to the list of woodcuts. It has been the object of the translator to adhere as closely as possible to the original text, so far as this was compatible with readable English. Throughout the work, the measurements and weights adopted by the author have been retained; but their equivalents in English measurements XVI and weights have ererywhere been added within brackets. A similar plan has been followed in cases where the size of objects is compared to that of Prussian coins. Notes have been appended to the various tables of weights and measurements, showing how these may be readily reduced to their corresponding English equivalents. A few other short notes have been added, giving an account of the composition and properties of the German Spas, and of various preparations of the Prussian Pharmacopoeia, and also explaining several matters referred to in the work, with which few English readers can be expected to be familiar. It has been thought that, by these notes of explanation, the practical utility of the work might be enhanced. 79 WiMPOLE Street, W., June, 1860. EXPLANATION OF FRONTISPIECE. Fig. 1. DLsintegrating glandular cells of liver (b) and bundles of needle-shaped crystals of tyrosine (a), from a case of acute atrophy of the liver. See Observation XIV., page 140. Fig. 2. Blood from the hepatic vein of the same case as Fig. 1 : a, crystals of tyro sine adhering in radiating bundles; b, normal blood- corpuscles. Fig. 3. Crystals of tyrosine which separated from a decoction of the liver upon cooling ; from the same case as Figs. 1 and 2 : a, crystalline masses impregnated with coloring-matter ; J, long needle-shaped crystals. Fig. 4. A fragment of the parenchyma of the liver, from a case of acholia arising from impermeability of the bile-ducts. The secreting cells have become almost entirely disintegrated, and their place is supplied by bundles of acicular crystals of tyrosine, and globular masses of leucine deposited in concentric layers. See Obser- vation XtX., p. 167. Fig. 5. A drop of urine passed by a patient laboring under acute atrophy of the liver, and evaporated upon an object-glass. It exhibits leucine deposited partly in globular masses, with concentrically-thickened walls and fissured surfaces, and partly, in finely-striated laminoe, and also greenish-yellow crystals of tyrosine. See Observa- vation XV., p. 142. Fig. 6. Greenish-yellow globular masses of crystals of tyrosine deposited sponta- neously from the urine of the same case as Fig. 5, after standing in the cold for twenty-four hours. Fig. 7. Ciystals of pure tyrosine obtained by re-crystallization from the same sed- iment as mentioned in the description of Fig. 6. TABLE OF CONTENTS CHAPTER L PAOS JJistoi'icfd lntroduetilood 113 E. Jaundic ■ from tyjihus 118 F. P>!l!ous fevers and tiie epidemic foi'ias of jaundice 124 a. The intermit' ent ami remittent malarious fevers 126 h. The reeurre.'it lever '■" relapsing fever '") 127 c. The yellow fever 129 The cause's of nervous symptoms in the bilious forms of fever and the eftV^cts of bile introduced into the blood 130 d. The most important epidemics of jaundice 132 CONTENTS. XXV PAOTI Appendix to Chap. IV i 133 1 . Jaundice in new-bom infants 133 3. Jaundice in pregnant females 135 CHAPTER V. Suppression of the functums of the Liver. — Aeholia and its consequences 136 A. The acute or yellow atrophy of the liver 137 I. History and literature . , . . , 137 II. Symptoms 138 III. Illustrative cases of the disease 140 IV. Analysis of the symptoms 153 1. The premonitory symptoms 153 2. The skin 153 3. The organs of circulation , 153 4. The organs of respiration 154 5. The organs of digestion 154 6. The urinary organs 155 7. The nervous system 156 V. Duration and modes of termination 157 VI. Anatomical lesions 157 Vlt. Theory of the disease IGO VIII. Etiology 164 IX. Diagnosis 165 X. Treatment ' 166 Aeholia resulting from other structural diseases of the liver 167 B. From softening of the liver supervening upon obstruction to the flow of bile. . 167 C. From cirrhosis 170 D. From fatty degeneration 173 CHAPTER VI. Chrome Atrophy of the Liver 174 I. Causes and mode of production 174 Various forms of this dependent upon structural changes in the liver, com- pression, &c 174 Atrophy resulting from obliteration of the capillaries of the liver in conse- quence of inflammation of Glisson's capsule 176 Atrophy resulting from occlusion of the hepatic capillaries by pigment 181 Atrophy of the liver accompanied by chronic inflammation of the intestine. . 184 Effect of obliteration of the portal vein upon the nutrition of the liver 188 II. Consequences of chronic atrophy of the liver : its symptoms 193 III. Modes of termination 194 rv. Diagnosis 194 V. Treatment 194 CHAPTER VII. The Fatty Liver 198 I. Pathology of fatty liver 196 Occurrence of fat in the liver, under normal circumstances, in the lower animals, and in man 196 XXVI CONTENTS. PAG> Influence of diet 197 Experiments by feeding animals 198 The injection of oil into the portal vein 198 Constitutional predisposition to the deposit of fat 200 The fatty liver which accompanies pulmonary tubercle and other consump- tive processes, and which occurs in drunkards 200 Fatty degeneration resulting from disordered nutrition of the liver 201 II. Structural characters of fatty liver 202 III. The amount of fat 206 IV. The general anatomy of fatty liver 206 V. Frequency with which fatty liver occurs 209 Tabular view of the occurrence of fatty deposit in the liver in different diseases, determined by microscopic examination 210 VI. Pathological importance of fatty liver 213 VII. Effects of the deposited fat upon the function of the liver and upon the entire system. — Symptoms of fatty liver 213 VIII. Diagnosis 215 IX. Treatment 219 appendix: 231 A OLINIOAL TREATISE OK DISEASES OF THE LIVER CHAPTER I. HISTORICAL INTRODUCTION. It is very interesting to trace historically the views which medical men at different periods have formed concerning the functions of individual or- gans of the body, and the diseases to which these organs are liable. The tree of knowledge, with its flowers and fruit, appears less strange to us, when we follow its roots, as they branch out, at one time more deeply,^ and at other times less so, into the region of history, and when we search out the springs which have made it bear fruit. That which at the present day is brought forward as new has not unfrequently been known centuries ago- With regard to no organ does history attest a change of views in a more remarkable manner than in the case of the liver.' This organ and the portal venous system attracted at a very early period the attention of physicians. More from vague conjectures than upon clearly established grounds, the seat of various functions, of great importance both in health and disease, was transferred to this powerful glandular organ, and to the extensive system of vessels, which is intimately connected with the gas- tro-intestinal canal. By the ancients the liver was regarded as the cen- tral organ of vegetative life." Galen looked upon it as the focus of ani- mal heat, and as the organ intended for the formation of blood, and for the origin of the veins. ^ According to him, the metamorphosis of chyle into blood commenced in the portal veins, but was completed in the liver, ' See Beau, Arch, gener. de Med. 1851. ' Plato, in his Timseus, calls thelivei' a epe/x/j-a Hypiov, on account of its importance in vegetative life, and in opposition to its asserted spiritual signification. See Galen, de dogm. Hippocr. et Platonis. ^ De usu partium, libr. IV. In hepate, quod supponitur venarum principium esse, primum sanguificationis instrumentum. Vol. L— 1 2 HISTORICAL INTRODUCTIOI?". which organ, during the process, separated as waste matter from the blood the yellow and the black bile, the former passing to the gall-bladder, the latter to the spleen.' Galen's views underwent scarcely any modification by the Arabian physicians, and remained undisputed until the middle of the seventeenth century. Even Vesalius, who, by his anatomical researches, contributed more than any one else to the overthrow of the doctrines of Galen, did not venture to oppose his physiological theories respecting the liver; he only denied the assimilative property attributed to the portal veins." The attempts of Argentieri ' to restrict the functional importance of the organ met with no support. The discovery of the lacteal vessels by Aselli in 1622, and of the tho- racic duct by Prequet in 1647, first imparted a severe shock to the views of Galen. A way had been discovered, by which the chyle was conveyed from the bowel into the blood quite independently of the portal vein and of the liver ; henceforth neither of these structures appeared to serve any purpose in sanguification. Bartholin * and Glisson ' were the first who enunciated in a decided manner this opinion. It rapidly spread; and the more readily, inasmuch as the revolutions just effected in the views of physiologists by the labors of Harvey,* bestowed an importance hitherto unknown upon the organs of the chest. Riolan, indeed, and after him De Bils, endeavored to defend the im- portant part played by the liver in sanguification, in opposition to the views of Bartholin; but Bartholin came victoriously out of the contest, and wrote for the liver a humorous epitaph, in which the end of its domin- ion was announced, and in which its function was declared to be hence- forth limited to the secretion of bile.' For almost two centuries this opinion continued generally to prevail. Swammerdann, it is true, endeavored to advocate once more the ancient theory, yet with so little success, that Boerhaave observed: " Dudum in meliori parte Europie obsolevit hsec sanguificatio nunquam ab eo viscero expectanda." It was reserved for the experimental physiology of the present century to extend the boundaries of our knowledge in this matter, and to repro- duce, in a more novel and exact form, opinions which, for a long period, had appeared buried in oblivion. The first step in this direction was made by Magcndie * and Tiedemann,° who furnished the proof that the absorp- ^ Prius elaboratum in ventriculo alimentum venae ipsEe deferunt ad aliquem con- coctionis locum communem totius corporis, quern hepar nominamus. De usu par- tium, libr. IV. - De corporis humani fabric;!, 1543, libr. III. 267, libr. V. 508. Quod vero iidem rami, priusquam jecori succulentum id porrigant, rudem aliquam sanguinis formam cremori seu succulento illi conferant, et ut Galenus attestatur, mode jecori simillimo istud prseparent. non facile concesaero. " De erroribus veter. med., Flor. 1553; and, Comment, tres in art. med., Galeni. Paris. IS.IS. •* Va'a lympbatica nuper in animantibus inventa et hepatis exequiae. Paris, 1653. * Anat. hepat., p. 289. Edit nova. Amstelodami, 1665. ^ Harvey himself attached little weight to the lacteals, and upheld the views of Galen in respect to the liver. ' Defensio lacteonim et lymphaticorum contra Riolanum. Hafniae, 1655. Bartho- lini responsio de experimentis Bilsianis et difficili hepatis resurrectione. Hafniee, 1661. ' Precis elementaire de physiol. Tom. II., p. 268. ^ Tiedemann et Gmelin, Versuche iiber die Wege auf welchen Substanzen aus dem Magen und Darmcanal ins Blut gelangen. Heidelberg, 1820. HISTORICAL INTRODUCTION. 3 tion of nutritive matters is not solely the work of the lacteal vessels, but that a part of the food digested in the gastro-intestinal canal is taken into the blood through the portal vein. Tiedemann and Gmelin moreover, by a series of careful experiments, arrived at the result, that " the liver must also be regarded as the organ for the assimilation of substances which have been absorbed from the intestine." The more recent investigators who have paid attention to this subject, such as Blondlot,' Claude Bernard,' Lehmann,* C Schmidt, and others, have been obliged to corroborate the opinion as to the participation of the portal vein in the absorption of materials from the intestine into the system, although much remains doubtful as regards the extent and impor- tance of this participation. It is to be regarded as clearly proved that water, salts, sugar, odoriferous and coloring matters are, for the most part, conveyed to the blood by venous absorption, as also that the greatest part of the fat reaches the blood through the lacteals. But it is still a matter of question, in what way the most important principles of nutri- tion, the albuminous, are absorbed. Claude Bernard and the majority of the French investigators make their absorption take place through the veins, whilst Lehmann, Schmidt, and Ludwig are convinced that it is through the lacteals. Another point which has not been sufficiently investigated, is the in- fluence which the hepatic parenchyma exercises over the substances which pass through it. According to the experiments of Claude Bernard, Mialhe, and others, the carbo-hydrogens, no less than the albuminous principles, in their passage through the portal system, undergo im- portant changes from the action of the liver, by means of which they first become fitted for the formation of blood. A detailed proof of this metamorphosis has not, however, as yet been given with sufficient clearness. At the conclusion of the work, we shall return to this and to other physiological questions of a general nature, and shall bring together such materials for their solution as present themselves; in the meantime we shall only make a few historical remarks, showing how the important part played by the liver in the absorption and elaboration of the products of digestion came by degrees to be again recognized. Whilst experiment proves that the liver exercises an indirect influ- ence over the formation of the blood, there are not wanting observations which seem to indicate that it participates directly in the generation of the elementary principles of this fluid, although, taking everything into consideration, these observations cannot be regarded as decisive. Among these may be mentioned the observations which Reichert,* E. H. Weber,* and Kolliker * have made upon embryos, and upon frogs wakened up out of their winter's sleep, in reference to the development of blood-corpuscles in the liver. These observers found in this way a remarkable confirma- tion of the differences between the blood of the portal and hepatic veins, which had been authenticated by the carefully repeated chemical analyses ' Essai surles fonctions du foie. Paris, 1846. " Lemons de physiologie experimentale appliqu^e i la medecine. Paris, 1855. 2 Physiolog. Chemie., Bd. III. * Entwickelungsleben in Wirbelthierreiche. S. 22. ' Berichte der koniglich sachsischen Gesellschaft der Wissenschaften zu Leipzig, 1850. S. 15, bis. 20. « Henle's und Pfeufer's Zeitschrift. Bd. IV., S. 147, ff. 4 HISTORICAL IITTEODUCTIOH". of Lehmann/ and by the changes which, according to the observations of Moleschott, the entire blood undergoes after the extirpation of the liver. Besides this direct and indirect participation in the formation of blood, we have very recently become acquainted with the part played by the liver in certain metamorphic processes of an intermediate nature, which are of the greatest importance, as furnishing a deeper insight into health and disease. Bernard ' has shown, by a series of accurate and precise experi- ments, that, notwithstanding that an animal is fed upon nitrogenous food solely, there is always formed in the liver, in addition to bile, a consider- able quantity of sugar, which passes into the mass of the blood, to serve an ulterior object, and which appears as necessary for the healthy per- formance of vital processes as are other metamorphoses, the products of which are thrown off from the system by secreting organs. In addition to this elimination of sugar from the complex atoms of the albuminous principles, other chemical changes take place in the liver, of which we shall hereafter learn the importance. This is shown by the ex- istence in the gland of inosite, hypoxanthine, and uric acid, and further by observing in it in the course of many diseases, the occurrence of cys- tine, and large quantities of leucine and tyrosine, and lastly, by the re- markable abnormalities in the composition of the urine which are observed in certain diseases of the liver. Besides all this, the important part v/hich the liver plays in the production of animal heat has found a new defender in Claude Bernard.' The liver has consequently again ceased to be regarded as merely an organ for secreting bile. The views of Galen, which Bartholin believed he had overthrown forever, although modified and circumscribed, have risen into new life and significance. There can now be no doubt, that in this gland processes go on, which exercise an impoi'tant influence over the principal vegetative functions — sanguification and the metamorphosis of tissues; what remains to be done is to ascertain at the sick bedside, and by means of experiment, the extent of these processes, and to fix with precision their influence upon health and disease. As might have been expected, this change of opinions concerning the physiological relations of the liver could not fail to react upon the views entertained as to its pathology. In these views similar changes are met with; only they are less remarkable than in the case of the physiological opinions, because clinical observations must always be directed to the se- cretion of bile as the chief function of the liver. In the pathology of the ancients, and particularly of Galen, the liver and tlie portal system served as the starting-point of manifold disturb- ances. There were described not only a host of anatomical and functional lesions of the organ itself, such as inflammation, abscess, obstruction of the ducts, and the different conditions resulting from intemperance, but a large proportion of constitutional diseases were referred to the same source. Abnormal conditions of the liver were regarded as the principal cause of changes in the constitution of the blood. " Sanguijicatio vitia- tur Jiepate vitlato.'''' Plethora, ana?mia, cachexia, and dropsy, were attrib- uted to certain changes in the activity of this gland. A further cause of general diseases was found in the roducts of the secretion of the ' Berichte der ktinic^lich sachsischen Gesellschaft der Wissenscliaften. 1851. S. 131, ff. '^ Xouvelle function du foie, itc. Paris, 1853. ^ LeQons dephysiol., Expurim. I., p. 109. HISTOKICAL INTRODUCTION. 5 organ, the yellow and black bile, which under a humoral pathology, had a mighty importance as elementary constituents of the organism. The yellow bile, it was thought, would induce acute diseases running a rapid course and accompanied by a high temperature, such as ery- sipelas, &c. ; while, on the other hand, black bile was believed to give rise to chronic diseases, such as mental derangement, apoplexy, convul- sions, &c. No wonder that in this way the liver came to be regarded as the centre of a large proportion of pathological processes. Throughout the pathological works which appeared from the time of Galen dov/n to the middle of the seventeenth century, this organ was looked upon as the seat of the mind itself. No one dared to question the grounds of this dogma, although in a few instances it was extended or modified. Even in the year 1626, Riolan called upon physicians diligently to study the liver, as the vltceet nutricatus fundamentum. The discovery of the lacteals effected a change in physiological views, which was necessarily followed by a reaction of the theories of disease. One of the foundation-stones upon which the artificial fabric of Galenic pathology had rested, was removed; opinions, which through a length- ened period had apparently acquired the value of facts, became untenable; and novel points of inquiry were opened up. Although the functional importance of the liver had necessarily become circumscribed, other chan- nels of absorption before unknown had been discovered. Simultaneously with this, the brilliant work of Harvey upon the circulation of the blood was attracting much attention, and promised an explanation of many phenomena. It was Bartholin,* the strenuous opponent of the Galenic theories, who had the merit of undertaking a revision of the science of medicine, under the light of the new discoveries in physiology. With a degree of caution worthy of all praise, he declared that the ancient medical doctrines were not overthrown, but only elucidated; that the causes of disease were better understood and more correct than formerly, and therefore more easily obviated; and that especial attention was to be given to the heart as the organ for the circulation of the blood. It was, however, admitted that abnormal conditions of the blood might result from obstruction and other diseases of the liver, although this organ did not take any part in sanguification. The obstinate adherents of Galenic medicine in vain en- deavored to combat these innovations; the views of physicians became modified more and more, and as a substitute for the dogmas formerly prevalent, they hastened to turn the discoveries of the day to a theoretical and practical account. There is a tendency in the human mind to overrate the importance of new discoveries, and in this way to make an improper use of them. Hence, we can quite understand how crude medical theories should have succeeded the revolutions above mentioned in the departments of anatomy and physiology, and the more so as, at the same time, a more correct knowl- edge of natural philosophy and chemistry was beginning to shed a new but deceitful light upon many questions. For practical medicine is gen- eral, and for the study of diseases of the liver in particular, there com- menced an unproductive period, which, trusting to theory more than to actual observation, always failed in obtaining a firm foundation in facts. The followers of Sylvius, the latrochemists, as well as the latrophysicists, left behind them no fruits of direct investigation on the subject with which ' An hepatus funus imrautet medendi methodum. Hafnias, 1653. 6 HISTOEICAL INTRODUCTION. we are now engaged. The theory of Franz de le Boe Sylvius, who main- tained that the fermentation of the juices secreted by the spleen, pancreas, and liver, was of great importance for chylification and sanguification, both in health and in disease, acquired a wide-spread influence, only be- cause it compensated for the opposition bestowed, since the discovery of the thoracic duct, upon the Galenic method of explaining many diseases, which, it was believed, must necessarily result from a disturbance in the functions of the liver. Not much more resulted from the writings of Sydenham, except that he re-established the Hippocratic method of clin- ical observation, and removed the abuses which had resulted from crude sources of information. Considering his great distinction in the practice of medicine generally, he bestowed but little attention upon the disease of the liver. Meanwhile, and partly even before this period, a better future was gradually being opened up through the anatomical and pathological in- vestigations to which physicians had begun to devote themselves with in- creasing zeal. In this way there was accumulated by degrees materials, from which a future age was able to construct the foundation of a pathol- ogy of liver diseases founded upon facts, although, certainly, one-sided. Even before the general revolution in medical opinions, Benivieni,' Vesa- lius," and Fallopius' had, from their anatomical studies, collected con- tributions which served to cast a new light over several forms of hepatic disease. They were the first to give accurate descriptions of gall-stones, and of the consequences which resulted from their detention in the gall- bladder. Vesalius reported a case of bursting of the portal vein in con- sequence of cirrhotic degeneration of the liver; he noted the prejudicial effects of spirituous liquors upon this organ, and the connection between intumescence of the spleen and disease of the liver. The writings of Glisson* contained some valuable observations upon the subject of tumors of the liver in rachitis; abscesses and concretions were treated of by Bartholin ;' malignant jaundice by Baillou,* a very able physician, and especially by Th. Bonnet, in his large and comprehensive work.' The last of these authors recorded an instructive series of cases of jaundice depending upon obstruction, and divided his observations under the heads of Inflammations, Tumors, Scirrhus, Obstructions, Cysts, Calculi, &c., of the Liver. It is true that these observations, in many places, require sharp criticism; yet, as the first rudiments of our knowledge, they are of much interest. Bonnet's description of Cirrhosis, indeed (Sect. J., Ohserv. 4), leaves little more to be desired. Sylvius, and afterwards Boimet, discussed at full length the importance of the liver in general pathology.* Although, in the present state of our knowledge, these early drawings ' De abditis morborum causis. Cap. 3, pp. 94, 140, 263. * Epistola de radie. Chin. Basil., 154(3, p. 642. 2 Ob.serv. Anatom., p. 401. * Anatom. hepat. * Historia nnat., Cent. VI. « Ballonii opera om. Genev., 16G2. Tom. I., p. 188. ' Sepulchre turn anat. Geneva;. 1GT9. ^ Wenn die Leber kalt seinnd die sauren Safte, die von der Milz herkamen, nicht verarbeite, .so eutstehe eine manjjelhafte Fennentation, der Chylus werde unvollkom- nien, das Blut bleibe seros und Wassersucht bilde sioh. Wenn die Leber heiss sei, so entstehe unprissende Fermentation, welche Fieber, Entziindung Putrescenz bedinge, Untcr I'mstunden Icterus, Diarrhoe, Cholera, Dysenterie einleite. Bei verstopfter und scirrhotischer Leber entstanden Cruditaten versohiedener Art (p. 2Q et seq.). HISTOEICAL INTEODUCTION. . 7 of anatomico-pathological investigation may appear incomplete and defec- tive, yet they were of great weight at a time when every well-grounded fact removed entire series of false theories, and formed starting-points for new studies rich in results. All the information concerning diseases of the liver, which in the course of time had been obtained through these investigations, J. B. Bianchi endeavored to bring together in his work entitled, Historia hepatica seu Theoria et Praxis omnium inorhorum hepatis et bilis. This work, although it went through three editions, contained much that was crude and carelessly done, and therefore deserved the severe criticism which it suffered at the hands of Morgagni and Haller. Its influence upon the further study of hepatic diseases was limited, and the more so, as, soon after its appearance, transcendent geniuses brought facts to light which necessarily eclipsed all that had gone before. H. Boerhaave and G. E. Stahl appeared in the field of clinical medicine; J. B. Morgagni in that of pathological anatomy. H. Boerhaave, who, in combining the artificial system of Sydenham with the fundamental investigation of nature, was a bright example to later times, paid particular attention to the diseases of the liver, because in them he believed he had discovered the source of a large proportion of chronic diseases.' A disturbance of digestion, resulting from a defi- cient secretion of bile, Boerhaave believed to be the cause of a faulty chylification, from which proceeded dropsy, cachexia, leucophlegmasia, &c.'^ In addition to defective assimilation, the stagnation of blood in the portal vein was considered as a second source of morbid conditions of the liver. The retardation of the blood at this part of the vascular system was, in Boerhaave's opinion, independent of the heart's action,* and was brought about by the contractility of Glisson's capsule, and the pressure of the abdominal viscera. Hence, it was thought, stagnations of blood often occurred at this place, and black bile was formed, which gave rise to obstruction of the viscera, especially of the liver, to hypochondriasis, melancholia, and many other diseases.* In his treatise. Hepatitis et Icterus multiplex, which Boerhaave declared to be one of his best works, there is a comprehensive account of the special pathology of the liver. It is remarkable, however, that the changes in physiological views among ancient physicians should have failed to effect any essential alteration upon pathology. Almost at the same time, G. E. Stahl,* relying less upon facts than upon theoretical reasoning, endeavored to claim for the liver a very com- prehensive pathological importance. He called in question the opinion as to the exclusive participation of the lacteals in the absorption of nutriment, which, since the discovery of the thoracic duct, had gradually become generally admitted; and at the same time he maintained, that as ' Praelect. academ. Ed. Haller, Vol. III., p. 186. Duo viscera svint, a quibus fere anne omne morborum chronicorum genus oritur, pulmo a quo tabes, hepar, a quo in- numerabiles lenti morbi. Ibid. p. 190. Atqui ex centum morbis chronicis vix unus, cujus princeps sedes non sit in hepate. * Quanqiiara bilis languet, nata est origo morbi alicujus chronici ; chylus enim non potest legitime pra^parari, inde hj-drops, cachexia, leucophlegmasia, &c. ^ Sanguis enim venje Portarum .... amittit omnem a corde acceptum im- petum, he. cit. III., 183. Cum sinus Portarum pariter sit cor hepatis uti cor dictum universe corpori. Ibid. p. 116. •* Prax. medio., pars V. p. 48 et aeq. ' De vena portaj, porta malorum hypochondriaco — splenetic© — suflfocativo, hyster- ico — colico hffimorrhoidariorum. Hal., 1698. 8 HISTOEICAL INTEODUCnOlS". large a quantity of chyle was carried with the blood through the mesen- teric veins to the liver as that which found its entrance into the system through the lacteals. The absorption of improper ingesta into the vena porta was regarded by him as an important source of the changes in the contents of this vessel. Neither Stahl nor Boerhaave believed that the circulation of the blood in the portal vein depended upon the heart's influence, but upon that of the respiratory organs, and upon a pecu- liar tonic motive power, which was imputed to the abdominal organs, and especially to the spleen, the intestines, and the mesentery, as well as to the coats of the vessels themselves. The diseases of the vena porta — to which Stahl referred those of all the abdominal organs with which this vessel was connected — were reduced to four elementary forms, from which was constructed a theory of the most heterogeneous pathological processes: — 1. Abnormal capacity; con- traction and dilatation. 2. Increased consistence of the blood, resulting from the absorption of ingesta which are acid, feculent and thick with mucus, from sluggish respiration, &c, 3. Passive stagnation. 4. Active stoppages in the circulation of the blood, resulting from the above-men- tioned relaxation and constriction, and from anomalous changes in posi- tion of the thickened blood. Although the physiological proof of these views, and of the conse- quences resulting from them, necessarily remained defective, still the doctrines involved in them were not without some influence upon the suc- ceeding age. Stahl, it is true, found but few supporters among his con- temporaries, or even afterwards among medical men generally; but the theory of abdominal plethora, and of the stagnation of blood in the bowels, which at a later period was elevated by Kampf ' into the doctrine of In- farctus, remained a standing and important article of pathology, which even at the present day attracts many supporters among physicians, and among the lay public has acquired the power of a confession of faith. The careful study of abdominal diseases was greatly prejudiced through this vague doctrine offei'ing- an easy explanation for every case. V\ liilst, on the part of physicians, many things were being done which must have retarded rather than have advanced progress, J. B. Morgagni"^ was collecting a rich store of anatomical facts and clinical observations, for which he secured an imperishable value, even in recent times, owing to their clearness and to the care with which they were worked out. For most of the diseases of the liver, we find in his works, the outlines of what is currently accepted at the present day.' After the time of Morgagni, anatomical investigation was pursued with greater zeal, and acquired in- creasing importance in the clinical study of diseases generally, and of those of tlie liver in particular. The several structural changes of this gland became more clearly understood, and distinguished from one another: and tlieir nature and consequences began to be placed upon a surer foundation, for which end the increasing study of the finer tissues by means of the microscope furnished still better and more convenient ways and means. Tile information upon this subject, which was contained in the works of Lieutaud, A. Portal, Matthew Baillie, Carswell, Andral, Cruveilhier, Roki- ' Abhandlung von einer neuen Methode. die hartnaokigsten Krarikheiten, die ihren Sitz iin Uuteilcibe haben, besonders die Hypochondrie, sicher und griindlich zu heilen. Frankfurt und Leipzig-, 1 T"??. ■■' De sedibus et causis morborum per anatomiam indagatis. Ebroduni, 1779. * Vide Epist. 2vXXVIl., on Jaundice. mSTOKICAL LNTEODUCTION. 9 tansky, and many others, formed a solid nucleus, around which the modern pathology of the liver has arranged itself. At the very time that the anatomical element was acquiring weight and influence in the investigation of liver diseases, the pathological im- portance of the organ in diseases generally was gradually losing ground. It is true, that Van Swieten and his contemporaries upheld the views of Boerhaave in their essentiality; it is true, likewise, that at a later period, owing to the then prevailing epidemic constitution, the bile assumed a degree of importance in pathology such as it never had before, and to such an extent was this importance exaggerated, that even Kampf's doctrine of Infarctus found a hearing. Still all this was of short duration; the labors of anatomists, the chemical analyses of the bile, the physiological experiments upon the secretion and uses of this fluid, and the study of the digestive process, year by year, removed the grounds, on which the com- prehensive general importance of the liver, both in health and in disease, had hitherto been based. After the discovery of the elementary composition of the bile, the liver came to be regarded as the organ which purified the blood of its carbona- ceous products, and as being in this way vicarious with the lungs; scarcely a trace remained of the views entertained by the old physicians, that the organ exercised a manifold influence over the formation of the blood. The study of liver diseases acquired in this way the simple anatomical character which we recognize at the present day ; and owing to this study being cultivated more on the dissecting-table than at the sick bedside, the investigation of the more obscure functional disturbances of the liver itself, and of its participation in other acute and chronic diseases was gradually discarded. That which had been stated and written by the ancients upon the subject was looked upon as the fictions of an age long past. Modern physiology, however, has effected great changes in this depart- ment, and has opened up many new points of view from which to study the question. The secretion of the liver has been carefully examined; the composition, origin and uses of the bile have been closely investigated, and in it, as a constant result of the secreting activity of the gland, sugar has been detected, although the physiological importance of this substance is still obscure. Further, there has been shown to exist in the liver a large quantity of the products of retrograde metamorphosis, which indicate a complicated transformation of materials within the organ, the extent and importance of which, however, still remain to be determined. Lastly, ob- servations have been made which seem to speak in favor of a direct par- ticipation of the liver in the formation of the blood. The task of proving and turning to account these new views will be- long to pathology; but there are many difficulties which stand in the way of its performance. Quite independently of the defects which are exhib- ited almost everywhere in the physiology of the organ before us, and which are sometimes of so important a nature that great caution is neces- sary in applying our knowledge of its physiology to the investigation of its pathology, the careful study of liver diseases is impeded by the con- cealed situation of the organ, by the fact of its secretion being poured high up into the intestinal canal, by the connection of the organ with those parenchymatous changes, the products of which do not make their appearance directly in the excretions, and by the frequent coexistence of diseases of the liver with diseases of other organs which exercise an influ- ence over sanguification and the metamorphosis of matter, such as the digestive organs, the spleen, &c. 10 HISTORICAL INTEODUCTION. In the present work, therefore, many questions are merely announced in a preliminary manner, without our being able to solve them, while others, again, receive only a fragmentary solution. Our investigations, however, on this subject, promise to be not without results, provided we pay attention not merely to anatomical lesions, but also to the disturbances in the metamorphosis of matter by which these lesions are accompanied. A few references to the most important monographs on Diseases of the Liver are here annexed: — J. B. BiANCHi. Historia hepatica sea Theoria et praxis omninm morbomm hepatis et bills.— Tom, L et II. Fr. Hoffmann. De morbis hepatis ex anatomia deducendis. Also : De bile medi- cina et veneno corporis. Opera omnia phys. med. — Tom. V. J. Andreb. Considerations on Bilious Diseases and some particular affections of the Liver and Gall-Bladder. London, 1790. Saunders. A Treatise on the Structure, Economy, and Diseases of the Liver. Ger- man translation. Leipsig, 1795. A. Portal. Observations sur la nature et le traitement des maladies du foie. Paris, 1813. J. Abercrombie. On Diseases of the Stomach, &c. Edinburgh. German translation by Busch, 1833. Bonnet. Traite des maladies du foie. Paris, 1828 and 1841. G. BuDD. On Diseases of the Liver. London, 1845 and 1851. German edition by Henoch. The works, moreover, which treat of diseases of the tropics are of im- portance, especially in reference to inflammation of the liver; such as: — Annesley. Researches into the cause, nature, and treatment of the more prevalent diseases of India. Vols. I.. II., with plates. Cambay. Traite des maladies des pays chauds, et specialement de I'Algerie. Paris, 1847. Hasi'EL, Maladies de I'Algerie. 1852. Tom. II. CHAPTER 11. THE RELATIVE SIZE AND WEIGHT OF THE LIVEE IN HEALTH AND IN DISEASK In order to obtain positive data for the solution of many questions, I have deemed it necessary to ascertain the size and weight of the liver, both absolutely and in relation to the weight of the entire body, with greater precision than has hitherto been done. We are dependent upon such knowledge, not merely in a diagnostic point of view, for a correct scale from which to judge of the existence of abnormalities in the size of the organ, such as atrophy, &c., but we are still more dependent upon it for information as to the manner in which general and local diseases react upon the liver, and as to the extent to which this organ, under the differ- ent conditions of the system (resulting from age, sex, and certain diseases), participates in the changes of the nutritive principles. It would of course have been preferable to have arrived at a satisfac- tory elucidation of such obscure and complicated questions without having recourse to the force brutale des chiffres, yet by such means we may expect to obtain some precise data on which to base further in- vestigation. It is necessary to take the spleen into consideration at the same time as the liver, partly on account of its intimate relation with the organ secreting bile, and partly on account of the changes in volume of this gland which accompany the different species of affections of the liver, and which are of such importance in the diagnosis of obstructions of the vena portfe. The determination of the value of figures, as applicable to the pur- poses just mentioned, is a matter of no small difficulty, inasmuch as, even under normal circumstances, the liver exhibits remarkable differences, which, to a certain extent, cannot easily be accounted for. Hence it is not to be wondered at, that authors should have made widely different statements as to both the absolute' and the relative weight of the liver in healthy individuals. Bartholin estimated the relative weight of the liver in proportion to that of the body as 1 to 36; Haller, as 1 to 25: the aver- age weight of the gland was reckoned by Haller at 45 ounces, or .3.7 pounds, or 1.8 kilogramme; by Cruveilhier, at 3 pounds; and by Huschke, at from 4 to 6 pounds. According to my experience, the relative weight of the liver in healthy individuals may vary from one-seventeenth to one- fiftieth of that of the body, and in adults it fluctuates between one twenty- fourth and one-fortieth; the absolute weight at this period of life reaches ' The absolute weight of the liver usually rises and falls in proportion to the weight of the body, so that the term absolute can only be employed in a comparative sense. 12 A CLINICAL TREATISE from 0.82 to 2.1 kilogrammes (1.8 to 4.6 English pounds avoird.)' The observations from which these numbers have been derived, were made upon individuals who had died suddenly from accidents without losing any blood, and whose livers, on careful examination, appeared to be healthy. Cases in which there was abundant fatty deposit in the gland were excluded. There are, therefore, tolerably wide limits which must be exceeded before we can speak of a simple hypertrophy or atrophy of the liver as a pathological phenomenon. The circumstances upon which these differ- ences in the weight of the liver are dependent, have hitherto been only partially discovered. The most important of them are the following : — 1. Age, It is during the first stages of development that the organ is largest in proportion to the size of the entire body; even in the later months of foetal life, and still more so soon after birth, its relative weight declines more and more towards that which is observed at a more advanced age. It is still undetermined, whether the remarkable diminution observed during foetal life is of a uniform nature; many observations are opposed to such being the case. After birth, the entire gland, but especially the left lobe,' diminishes more rapidly in consequence of the altered supply of blood. During the period of greatest growth, the liver does not become enlarged in a manner proportionate to the increase of the entire body, and its diminution in old age is, for the most part, in advance of that of the body. The substance of the liver, therefore, presents in this respect a marked contrast to the muscular tissue of the heart, for whilst this, according to Bizot, increases progressively up to an advanced age, the mass of the liver diminishes. In old age, as a general rule, there is senile atrophy of the organ. Such are the results of weighing the liver in healthy individuals, as well as in numerous instances of persons who have died of other diseases in which the liver has not been at all involved. Exceptions occur, owing to the force of circumstances of an extraneous nature influencing the volume of the gland; but these exceptions disappear on adding together the larger series of figures and calculating the average.* ^ Similar differences were observed by Bidder and Schmidt ( Verdauungsdfte, etc., S. 15'2), in healthy animals, such as cats, in which the ratio was from as 1 to 14, to 1 to 38. " According to Portal and Meckel the liver in newly-born children ought to be one- fourth heavier than in children from eight to ten months old ; but my experience does not correspond with this. ■' The numljer of original observations as to the weight and size of the liver from which my calculations have been made, amounts to about 8(K). A large number of weighings appeared necessary, because numerous accidental influences, modifjong the v,-eight of the liver as well as of the entire body, such as hyperaemia and ansemia of the organ, dropsy, suppression, or profuse secretion of bile must be excluded. Space does not permit us to give here a detailed account of the numbers in each case. In the tables the measurements are indicated by Paris inches ; the weights, by kilo- grammes. ON DISEASES OF THE LIVER. 13 "S rr s •^i 3 « n g c^ > t!' -o <^ o 3 U^J o P » ■< o u «1 p 3 t o m B- P a t* ta H- hj g; -"' P s O o c rt- H rtl P B H^ a- o P o 1-1 Q re rr CD ■* V! n ^ p to o 1-1 §• CD " ts M CD H J^ 10 «^ c. ^^ IS o P- t(^ PjC! •rt ^ o ^ P, Oi <«J p CD p* 2 -• p B) 3 t; C R CD CD H 00 P* ^ H rt- p P* cr f»- Ci o^ -^ bo '-' H-" hy bOP— 'OTCncnooi— ' j^-acsCT ? CO CL "^ QQ ::i:;!::iii:!icL,Q ^ri •''•*!"!!!!!!Ir&->-»8 ''. \ ............ (^ "^ " P^ Op50C35OibSOHf>-rf^C»00r--'baC0v-'H-'i>0J-'P|= S o •< ct- Oh-'h-'*-'*— 'Pj-'H-'PppOOOOppOOfi^ O03OX00C5 OOi" It" 5' o Relative Weight of Liver to that of Body. >4i. OS rf^ *^ OS w to OS fci O O *4 ?0 Oi bi Oi H-" 1— ' O O Oi ►f^bO-JOSbObOUJbObOi-ibObO po'poosj-'potf'-po^H-'p OSOiOSbOCii— 'b^l— 'CnOOiOi p p p p p p p >— ' 1— ' 1— ' to 1— ' O fcO to en Oi Oi 00 bO p p p p p p p p p p p p j^ 1— '!—■)— lOOOOOOOOO^. Orf^ bOH-'Oi— 'I-.000 0(g OCS«Ol— '1— 'OOCirfi'LO.'^ fol W o 1 I| 53 OS050SbOOSrf>-bO*>'t— ' >f>'l— 'boost— 'IsSOSOSfcO O^atDb0^^Ot0O"f^>f>-OC5tOGO oxppji^pp^ps^poptH-'pooioipppipo bo' " ' ' K-'Oobob5rf>'biobioo It" I—" I— 'H- '1— ' 1— '1— '1— ' bOl— '1— 1 ^^-COO'pOOOppjf^bOO'h-'pp^j-'O'jf' oboo' loci* obobrbi* bofco* bi* o to ^ 1 ^ ^ ^ ~^ C5 1 1 cTiOsosbObobobotoostoir* 1 it4-tsf-t>:^^bcf-t4-**otMMK)H bcf- 1 S' h 1 i 1 I Ot *>. tn Oi 4>. 1 1 ►cf-*Ha.,;4-t=<->H- 1 1 OS*>>>f>'bOtObOl-'bOtOfcO|^ I Cl O CJi Cn Ox I 1 *H taH*+- 1 1 054>-OSt-'bObOb3bObOfcO|.^ 1 rf4-*^MtaH Ot-rfHMKf' 1 g- If 1 OS OS OS rf*- fcO 1 1 *f-rf4- t*- 1 1 OSbOh— h-"!— 'bOi— 'H- 'bOI— '[.'' 1 Kt-.**o*4»eeHiH» rf4-*+-ts>-*.)» 1 g. 1^ 1 bo bo fco fco fco 1 5" |OSi-'i-')-i I-" »-'»-' 1?? Thick- ness (great- est). 1 or Oi en rfi. OS I 1 *+- 1^ \ 1 ►i-i)-' 1.'' 1 tCt-Kf-tJH rfHMtCt-*+-«(-»=H«)« 1 g- 3 i B o" 3 s. •c P 1 i;>s OS OS to InS 1 1 *4-4JMl^ 1 hi 105U!H-.h-.l-i^l-i|-i |§ 1 1 iHuw1mi(>h>Ho>mH 1 I 1 ^ 1 *»:, H-tct-icH;^^«4-»+-^**- ' I. w < a GO o 1-3 » s o S3 d O » o >■ O o !z! O 14 A CLINICAL TREATISE 2. The Sex. According to Glisson, the liver, as a general rule, is heavier in men than in women; but an opinion precisely the reverse is maintained by Dumas. I myself have been unable to detect any differences dependent upon sex, except that in scrofulous women the liver is usually larger than in men, from the fact that, in the former sex, it is more frequently remark- able for an abundant deposit of fatty matter. 3. The Ingestion of Food exerts a powerful influence over the volume of the liver. During the sec- ond stage of digestion the organ increases in size and weight, partly owing to the state of congestion which then makes its appearance, and partly owing to the abundant deposit of granular and amorphous material in the interior of the hepatic cells. After a protracted fast, the gland becomes smaller and lighter. Bidder and Schmidt found that in cats the relative weight of the liver to that of the entire body was as 1 to 30, three hours after a meal ; after from twelve to fifteen hours, it was 1 to 25 ; from twenty- four to forty-eight hours after, it was 1 to 31; and after seven days' fast, 1 to 37. I have arrived at similar results in rabbits; under the influ- ence of a three days' fast, the relative weight, which after a full meal is, generally, 1 in 25, or 1 in 27, diminished to 1 in 34, 1 in 37, and 1 in 43, with a total loss in each case of 31.1, 29.6, and 17.8 per cent. The fol- lowing observations appear to indicate that starvation is followed by sim- ilar consequences in men. In a healthy individual, aged 27, who, owing to a fall from a scaffold, died with a full stomach, the relative weight of the liver was found to be as 1 to 26.5; in another person, aged 36, who perished under similar circumstances, it was as 1 to 37; on the other hand, in a man, aged 25, who died of trismus, after three days' complete abstinence, it was 1 to 40; and in a woman, 33 years of age, who died from burning the pharynx with sulphuric acid, after seven days' fasting, it was 1 to 50. From what has just been stated it may be concluded, that, in the man- agement of chronic congestions of the liver, a strict diet plays a powerful part in effecting a cure. In cases, however, of protracted starvation, which terminate in death from inanition, the diminution of the liver in propor- tion to that of the entire body, becomes again equalized. Thus, the fol- lowing observations were made in four individuals who died of stricture of the oesophagus: Weight. Relative weight of Liver to that of Body. Weight of the Spleen. Relative weight of Spleen to that of Age. Of the Body. Of the Liver. Liver. Body. 48 years .... Kilogr. 1 32.2 Kilogr. 1.1 1 : 29.2 Kilogr, :13 1:8.4 1 :247 50 " .... 30.8 0.92 1 : 33.47 — — — 65 " .... 39.0 1.20 1 : 32.5 :12 1 : 10. 1:325 44 " .... 39.7 1.75 1 : 22.7 — — ~~ ' 1 Kilogr. = 2.2046 English pounds avoird. ON DISEASES OP THE LIVER. 16 Still more remarkable is the influence of diet, when the food is very rich in fat, or when it is too bulky, while at the same time the powers of digestion are impaired. In this case the deposit of fat in the hepatic pa- renchyma induces an undue proportion in the size of the liver. Bidder and Schmidt found the relative weight under such circumstances to be as 1 to 16. Lereboullet ascertained, that in geese the relative weight of the liver varied from 1 in 26 to 1 in 18, after feeding for two weeks upon maize, and that after four weeks it rose to 1 in 12.8. How greatly the volume of the liver is influenced by nourishment may easily be seen by comparing a large number of observations on the weight of the organ in individuals who have died in pneumonia, typhus, and other febrile complaints. Its relative size under such circumstances is much smaller and more uniform than what it is when death has not been pre- ceded by protracted starvation. (See Table II.) 4. The Degree of Congestion of the Liver has a marked influence over its size and weight; changes result from this cause, which are of little importance, because the causes of the abnormal distribution of the blood have in a measure only a transitory and acciden- tal value. We are possessed of no means for completely comprehending the derangements which result from this cause, whilst the attempts to sep- arate the blood before weighing, by the injection of water, have induced other sources of fallacy. It is not improbable, that in addition to the influences just mentioned, there are still others which operate in changing the volume of the liver, so that the organ will be found sometimes exceeding, and sometimes smaller than, its normal proportions, according to the constitutional peculiarities of the individual. No certain proofs, however, can be furnished of the existence of such agencies, because we know not the limits to which other causes, which are at least partially understood, modify the size of the organ, and consequently, in some cases, we are not in a position to exclude these causes. The Mdative Weight and Size of the Liver in Disease. In order to obtain an insight into the manner in which the relative volume of the liver becomes affected in the course of general and local dis- eases, and as to how the organ becomes altered in size by morbid condi- tions of its own textures, several special series of measurements have been collected. The most important results of these measurements have been noted in the annexed tables. These observations furnish us with trust- worthy data for the solution of many questions, and their value will ap- pear in a subsequent part of this Work. 16 A CLnnCAL TREATISE h ^M - •si II. *883a 5 1— 1 I— 1 1— ( 1—1 l-t 1— ( I— 1 1— 1 I— 1 •+X j •qiproja geo ec ec eo eo eo CO eo eo iq H* 1 eo 1 •qi3u3T[ 5 So lO O lO >o to ?o iC iCi .«*< "0 1 i 1 .2 a o > "S 1 a o g 5 !j(M - Ah t- t~ 00 t- 1 ft > 3 CO CM T-( C^l -* O O l>i O l>I 00 CO CO CO* ^' I— 1 r—t '^ eo r-^^^l—l 1 -* t^ 0-1 ^ o CO O" 1 Ah Ah Ah r^ •>■ 1 >— 1 Li &0 CO cq CO ^ '^ 0-1 CO (M O-l i2 o o o o o CO -<*< d d O O -<*< O 0-1 0-1 —1 d d <6 C-l d 0-1 '^ CO t- 0-1 0-1 o" X t^ '— ' ci 0-1 0-1 0-1 0-1 0-1 x' r-' CO i>; x' 0-1 0-1 o ^ -^^ ^ 00 0-1 .-H* d CT CO CO 0^1 C5 co' 1 CO ' to 3 hco o 5 CO X q -o o 5 — H f-H Cl rH T— H ■>* CO eo o o o eo CO o t^ I— 1 rH r-H o 1 ^ _ tiO t- O uo b- 2 lo ci o CO !>: ^i! CO -* O ^ ^ CO i>^ d CO ^ o o oq o CO t>^ d .<*' ^ .^ CD O-l 1 0-1 CO 0-1 ^ ^ n C3 O 0-1 o CO CO eo 0-1 CO 1 c o 5 o o o - o (M ^ i- u; X «^^ :i :i :: iC o o o o >— 1 0-) ^ lO o o c 0-1 o t^ r-l C-1 o o cq O 't «3 0-1 t^ 'X> 0-1 "—i CO 0<) 1 o 1 CO 1 80 i >. • • -J" ^ . • • -*j 5 . . . -JS o £ a "o 9 == 3 8^ is ?^ o :-S : o g ON DISEASES OF THE LIVER. ir •i* •ssatniapix - 1 ^-t 1—1 I— t Hn-4* 1 I— t 1— 1 r— 1 1 t+o ,^1^ if •qjpTioja H« 1 *M '^'Hn •cH-Hn 1 esH< « 1 ec ioH>o kHiH* 1 3 Si-) 1 10 CO 10 1 CO "o a o » '-I -+*-*» "+?>-+)< --♦n Hn 1 KH< •a ^ ^^>3 ^ 1 10 10 CO 1 -^ a a *" ^ fl 3 II «H. 1 H» •-H*o:H* 1 Hn t- 1 t~ b- t^ t^ 00 CO l^ 1 t^ CD (M 10 10 CO -* O «*-i 00 • 1 -* vo <^> CO CO oq *J o t- t^ od oo' 00 -* >d ■>* CO !>I 1 d s 1 1— 1 ' 1— ' o'* !— 1 r^ -^ r^ r— 1 rll I— c I— C ^H r-H T— ! ^3 ^ e. ?0 ^ CO C^ b- T-H 21 ■^^ 1 CO 00 c4 QO' d d t^ CO (m' I d S 32 6 -■ <6 d> d ® 43 ■^'M ■* . l>. C> ^ 00 t^ CO 1 (H l^:^-« (r^_ ' T* ':! ^l (^^ c^ "^1 -^ OQ CM ' CO 1—1 r^ 1^ '^' r— 1 r-( '^" 1— 1 ,— ( r-( ?-H h & r— 1 Ci s' '^ 1 ■* CO t^ -* ■^ lO CO 1 "^ • ■43 s S M 1— ( ' r— 1 1—1 I— H I-H I— 1 1— 1 1— < ' — ' ^ ■c" ^ 9 1 t» 00 CS --H (M 00 ?^ 05 2 d ci ci 1— < CO CO CO 1 ^ 3 cc ^^ CO CO -<* (M -* ^ '^ is"^i 10 1 ^ ,-H CO CO — 1 (Tq c^ 1 ^--5 1 1—1 (M T— 1 1—1 fj 2 I a:> lO 1 '^ © § '^ 1 to 00 oi CO ^ CO 1 00 -^ - c: s« **■ ^ i: s c; n ® ! t- ^ 1 00 I CO Or-l-.<*!>a Ho «H •q?auai H»HtoHr-,^ ecHiesH* »|ao ■ ■--In Him M O -* "<* ■<*< '^ -* ^ -* CO »o o ^ •BsaiDioiqx H^Hw HH^ H* t+0«||tj1 n^-fx «^ i5 (M 0 kO »0 lO s a 3 i| ''H'V.clcoe*- «»l» «H. HrH-tM Hn 3 «i^ O t^ O CO CO t» t- lO «o »» b- t- *-( O lO — J o CO »o o o q CO "■^ 00 O I 00 t-^ CO i>^ o> CT CO -E"^ 3 l-H AI rM r^ AI I— ( '-' r^ AI I-H !-H I-H I-H ^ t^ l-H ~ 3 C-l 00 GO ^ I—I 00 r-; q l-H CO ^ ^ oo' co" -* t-^ CO CO OS 1=2" o — 1 Cl I- CM ;m o 1:^ C5 l-H -^ t^ 00 M '>T .-^ C-^ C- 1 <^1 I— I * CO CO < ■§« § aO CO O Ci CO CO o CM '^ (M O ■2 oiJ O r-H Ol I-H ^ w d d d d I— 1 d !■ fe--o CO o CO t~ xj< q lo q CO 00 o .-S d -: ^ d 00 d o d 00 i>: o W « -M -* -Tt* -t CO o t^ CO -* CO o fc- a r >* uo O t^ o CO CO r-< ^ ^ o o 1"^ 'T CO CO l-H I-H o c o o o O CO O C5 O (M O^I -^ — X' 00 t- CO CO lO 00 CO be i c^ ^ ^ -J ^ ^ ^ V* V* <;^ ** ** X* V* v# ^* v# p "^ ? S 9 o 05 1 « 1 00 00 ^-' - '. ^ 1 lO l-H 1 o 1 -* Cs| V. rA ° to . . «4H ^ v^ 02 K- 3 (u Ch . m 1 3 thout D til Drop nia — ft 5-d phag on), reme 5 S 1 •3 -r -^ 2? « -li> A. Wi B. Wi Carcino •s 1 1 1 5 •883u:|ontt o:H< i-f* r^N-f* 1 1 CO CO CO CO CO 1 1 11 O O lO o «|eo i-tso*0 HNe*0 1 1 lO lO O lO O II s 33 O lO to lO r4pn T-ife HNr+o 1 1 let* tJ< lO »0 »0 II II O t~ t^ O io|e mIwH® H^ 1 1 «0 ?D !>• t» O II u > 1: 7.7 1: 7.54 1 : 8.94 1 : 10.23 1: 8.61 1: 6.04 1: 8.09 1: 9.3 1: 9.79 1: 6.43 1:156.6 1:193.24 1:200.27 1:383.3 1:245.8 1:242.1 1:282.5 1:464.03 1:341.3 1:268.3 ? CO BOO OS -* O _0 I-H I— I 1-H 1-H i2 d o d d 0.23 0.17 0.14 0.13 0.19 EeUitive W.aght of Liver to that of Body. 1:21.06 1:25.45 1 : 28.6 1 : 36.02 1 : 28.53 1 : 35.4 1 : 37.9 1 : 47.6 1 : 37.2 1 : 41.25 1 3 cq tjco o t^ o O— H CO 1-H C=HS wImHw 0*0 Hn r+JlHcOlotl) 1 > 5 1 2; 1 (M xt< CO 'St* CO -* eo CO eo ^ 1 ^1 1 HqoHn "c|qo«H< «:H..*|« r+e 1 ^ ^ g3 1 O IQ O lO lO lO to lO CO t^ 1 «^' 1 a:H lO to «o to t~ t^ 00 1 05 CO I-H eo "S. I ^ o O Oi O 00 -1+ t~ to Cft 1 o -rt< O t^ CO CO o 05 "* 05 -* 1 p^CC pa CO CO I-H r-H r-H r-H rH I-H ^ (M 1-H (M • H 1-H 1-H I-H J 00 t^ a a & 1 ^ =o rH 00 to to 1-H • 1 CO -; C^ (M -r^H 1-H 1-H CO CO' r-5 1 C L «" ^5 1 iCi t>- CO ^ 1— ( I-H CM "■?. rH r^ '^ !M CO C^ 1 I-H r-i 1-H 1—1 CO u ti , i-H O o o t^ 00 1-H 00 00 to , > ° oc o o t- CO 1-H to to -* 1-H 1 to k-l W do 1-H 1-H 1-H 1 — 1 I-H 1-H rH CO ^ >. & , (M CO 00 o r-< O t- to 00 -!* "^ o .-2 ^•^• -* CO 1-H CO to' t>^ ic CO « -^i^ o '^ t~ eo t~- to ^ ^ lO c ^ U-* ^ 1 -*l ^ C5 CO (M l-H - ^ o o -4-3 *- rt i ^ O C CQ • rH O 05 ■s'g^^l *^^ ^^i . . c« . . fc/i •p, -^^ ■*r' U a < n^ 5 .33 CO CO (N CO 1 e**-^^ 3 |3 kO ■* O »Q ->* 1 o 1 CO 1 CO VO «i H^H^ 1 «*o 1 «l» 1 u^oH* o c C .33 lO ^ O CO "* 1 -* 1 »Cl 1 CO CO 1| eo|o»He» ,«£ E ^ Hn H»«+*< H'T^ 1 0*0 1 1-f* 5 .~ o »o lO CO 00 CO 1 t- 1 t^ 1 00 00 I 1-H 00* os' 1 ^ 1 J>I 1 l-H CO .fc 1-H 1 .. 1 .. 1 T^ .. 13 r^ AJ rH T^ r^ T— 1 I-H »— 1 r-H || o lO O OS OS O r-f^ OS o t^ CO 1— f aS t^ ^ 00 t-^ OS .-H 1 ^" 1 eo' 1 CO* i>I o lO lO C<1 CO -* 1 >o 1 00 1 c d> o t~ ss»^^ o t^ OS t^ i-i OS t>- -<*< >o is^-S-So 00 ^ oi --^ d 1 <^' I ici 1 1-H CO l.^"^ o" o "?. *?. CO CO 1 h; 1 — 1 (M O ^ w 1^ '^ (M OS J-. 1 *=*• 1 00 1 >-J CO n M«- d d 1-J CO 1 »« 1 CO 1 00* d CO o '^ lO lO CO CO CO )— 1 CO T— t 00 CO 1 "* 1 CO 1 (M 1-H !§ ^ 1 1 r-< 1 g ^ 00 CO t- 00 1 <^ 1 ''*< 1 (M t^ ^* s ^ ^ 1 <=> 1 -* t- 1 "* 1 t- 1 rH 1 1 o 1 eo (M 1 ■-' 1 rH 1 so 1 • • '. '. fl t^ • 1 ^ * >, .^ 1 03 09 0} . Ci. . &, . rt . • CD " '"^ *'^ _s t^ «*-c 't; 1 > 1 ft §- §3 ^^ n o O c " 02 "^ -M <0 o < ■A . . tD 's > ^ ja S est to employ a pleximeter divided into lines or centimetres, and a hammer. In order to ascertain the upper boundary, ON DISEASES OF THE LTVEB. 25 we ought to percuss from the third intercostal space downwards, until we arrive at a place where the sound is dull. Here the liver is in immediate contact with the wall of the chest ; above this lies the convex portion which is covered by a layer of lung gradually increasing in thickness as we proceed upwards. The breadth of this portion, the upper edge of which represents the true upper boundary of the liver, varies from two to five centimetres (four-fifths to two English inches) but usually amounts to three (one and one-fifth of an inch). In a case where precise results are desirable, we must map out the gland all around the right half of the chest as far as the vertebral column, and indicate its outline with lunar caustic. In ordinary cases, it is suflBcient to determine its boundary points in the course of the linea mammalis and liiiea axillaris, as also close to the vertebral column, and in the median line in front: in the last-men- tioned situation, this is best done by drawing a line from the point of contact of the right side of the cardiac dulness with the upper boundary of the liver to the apex of the heart. In order to define the lower border of the liver, we percuss downwards until we can distinguish the tympanitic sound of the stomach or intestine. By a percussion stroke of moderate firmness and elasticity this margin is usually made too high,' because the intestinal sound is transmitted through the liver, in cases where the margin of this organ is sharply attenuated, or where the underlying parts contain much gas. To define it with any amount of certainty, we must percuss very gently; and for this purpose, the mufBed mode of percussion recommended by Piorry, by making the two or three first fingers strike simultaneously, is of the greatest service. Fine distinctions of sound are in this way more easily recognized. A mistake of an opposite character not unfrequently happens, owing to the abdominal walls being rendered very tense in consequence of great pain in the epigastric region. Here, from the great muscular tension, the dulness corresponding to the situation of the liver is extended, an illusion which is increased still more by palpation. The inflammations and enlarge- ments {Aiischoppungen) of the left lobe of the liver, so frequently be- lieved to exist, depend for the most part upon this condition, which in practice is not sufficiently attended to. In cases where it appears necessary, we may mark out the lower bor- der in its whole extent, from the extremity of the left lobe nearly as far as the spinal column; but in most cases it is sufficient to determine it in lines corresponding to the nipple, axilla and sternum. By ascertaining the upper and lower borders at these three situations, we learn the meas- urements of a third part of the organ, from which we may draw conclusions as to its entire volume. These measurements, however, in healthy individuals, are liable to vari- ations of considerable extent, the limits of which must be determined before we can turn the clinical observations to any practical account. A large number of measurements appears to be necessary, in order to become acquainted with the differences arising from age, stature, sex, and other physiological conditions, and in order to ascertain the limits which cannot be transgressed without affording a certain proof of a pathological alter- ation in the volume of the liver. ' The situation of this margin can be made out with greatest certainty in cases in which the lower margin can also be felt on palpation ; the latter mode of observation almost always indicates the lower margin as somewhat lower down than percussion, unless this is made with great care. 26 A CLINICAL TREATISE TABLE I. Variations in Measurements of Liver according to Age and Stature. MALES.* Age. 1 I" 1 a 1 •3 Age. i c s 6 a e 1 S CQ '^ ^ cc 2 GQ 3 SQ Centim. Centim. 1. 10 mon. 67 4 H i 29. 22 years. 160 8 9 6 2. 10 " 69 5 3 2 30. 23 " 153 8 10 8 3. 5 years. 103 H 7 3 31. 24 '* 170 9 9 7 4. 6 " 99 6 6 4 32. 24 « 154 9 9 5 5. 7 " 98 H 7 3 33. 24 '* 154 10 10 6 6. 8 « 115 7 7 4 34. 25 " 150 10 10 6 n 1 . 9 " 102 7 H 4 35. 25 " 151 6 9 5 8. 11 " 125 7 6 3 36. 25 « 158 9 10 6 9. 13 " 125 5 H 3 37. 26 " 138 12 12 7 10. 14 " 124 7 6 6 ' 38. 27 " 146 8 6 3 11. 15 " 144 7 8 6 ^ 39. 27 " 160 10 9 5 12. 16 " 150 H 10 6 i 40. 27 " 160 11 10 8 13. 17 " 142 n 9 5 : 41. 28 " 160 11 12 8 14. 17 " 146 10 9 5 42. 29 " 150 9 8 6 15. 17 " 144 10 10 7 ' 43. 29 " 150 11 11 7 16. 17 " 162 10 8 6 44. 30 « 170 10 10 9 17. 17 " 149 8 7 5 45. 32 " 160 10 12 6 18. 17 » 154 8 9 7 46. 32 *' 154 11 11 6 19. 17 " 157 8 6 7 47. 34 '« 150 10 11 3 20. 18 " 151 8 7 4 48. 34 " 156 9 10 6 21. 18 " 150 10 9 7 49. 34 " 152 10 10 4 22. 19 " 156 10 10 6 50. 37 " 160 8 11 5 23. 20 " 155 12 11 7 51. 39 " 168 12 10 4 24. 20 " 168 9 9 7 52. 42 " 171 11 11 8 25. 20 " 153 9 11 6 53. 44 « 150 10 9 4 26. 21 " 155 9 10 6 54. 45 « 166 8 9 6 27. 21 " 155 8 9 5 55. 46 " 160 9 9 7 28. " 164 12 12 5 56. 55 " 155 10 10 4 * The meapurcmeiits in this and the following tables are given in centimetres. There are about 2^ centimetres in an English inch, or more correctly, 1 centimetre= .3937 English inch — TUAJsSL. ON DISEASES OF THE IIVEB. n TABLE II. Variations in Measurements of Liver aocording to Aob and Stature. FEMALES. Age. 1 S a 1'^ h "3 . E| Age. 1 1^ u 23 1 •S6 |3 1 Ccntim. Centim. 1. ^ yrs. 68 4 4 H 30. 30 yrs. 136 H 9 6 2. H (( 67 4 5 H 3L 30 (( 138 10 8 3 3! H (C 80 H H 2 32. 30 t( 139 10 9 5 4. 3 « 90 H H H 33. 30 « 132 10 10 7 5. H i( 76^ 4 4 5 34. 30 It 150 10 8 9 6. 4 (( 77 2f H H 35. 30 It 150 11 10 7 7. 5 (C 91 4 2 I 36. 33 ft 146 9 9 4 8. 5 (< 87 7 7 3 37. 34 (( 156 10 11 7 9. 6 (C 90 H 5 H 38. 35 (( 147 10 9 8 10. 11 (( 124 10 8 3 39. 36 « 147 8 8 7 11. 12 « 127 7 6 H 40. 38 (( 148 11 9 6 12. 14 (( 127 8 9 4 41. 40 tt 142 13 11 6 13. 15 (( 131 6 7 6 42. 42 it 152 8 9 5 14. 17 (( ' 150 9 9 6 43. 42 tt 142 13 12 7 15. 18 (( 139 10 10 5 44. 42 ti 142 9 8 4 16. 18 (( 154 6 8 7 45. 43 (( 152 13 8 6 17. 19 (C 136 8 9 7 46. 47 <( 150 8 9 5 18. 20 « 136 9 8 3 47. 48 (( 150 9 8 7 19. 21 « 142 6 7 4 48. 49 (( 136 9 8 7 20. 21 (( 138 7 8 5 49. 50 tt 140 9 8 8 21. 22 « 152 8 9 H 50. 52 tt 155 11 11 6 22. 23 « 146 8 9 5 51. 53 tt 144 9 10 8 23. 23 (( 158 9 10 5 52. 59 i( 148 10 10 7 24. 24 (C 147 9 8 5 1 53. 61 it 146 7 7 6 25. 24 « 152 8 11 6 ' 54. 69 tt 137 10 12 6 26. 26 (( 151 8 7 6 ' 55. 76 tt 146 9 7 4 27. 27 (( 150 6 8 5 ; 56. 79 It 144 8 7 7 28. 27 (( 152 9 8 6 57. 60 tt 154 10 8 5 29. 27 <*( eo i-i eo A CO r-l 1 1 1 I-H . '^i* 00 (M cot-eO'*osoOi— i-rt< 00 OS OS OC • - 1 •3 ^ G^ iG iQ ^£> CO CTeoeo-*o»oto>Q OS ?r) »:^ 00 ec t^ C 1 S ; -^* 00 Os" C5 i-H trq 10 CO OS CO 1 CO CO cO\CO 00 0" o> 1 pq M ^ f-H '— ' o CB . 10 »0 ■ -^ 1^ c. 2 CO 1 1 -* CO j l>. t- .-H CO -* b- c3 T^ OS OS -rJH 'cj^ t^ 00 OS OS OS . 1 S fe P p ^ co' OS OS OS ' 1 — i r—< till 11 !0 ' ' e -kJ ^ : • : M ^ s- - - - . ^H _ •« •j^^v.vv.v.^ ce .. ^ 1^ ! ^ •S mcoOiOOOOo ■« & y >> 5^2 ^ S ^ 2 S '-^ ir: ^ - i^ ^ ^ ■- ^ TO g>>^ ■ same time, as a consequence of the circular contraction, a part of the right, and usually of the left lobe also, becomes separated by a ON DISEASES OF THE LIVER. 83 depression, the situation of this depression being sometimes higher and sometimes lower, according to the locality of the lacing. The furrow thus formed often penetrates deeply into the parenchyma, till there remains noth- ing more than a loose ligamentous connection, which allows a free motion of the separated portion (Fig 6). Fio. 6. — Abscission of the right lobe of the liver, with thickening of the capsule. The serous covering of this portion always appears thickened, and of an opaque white, and the biliary ducts may be seen through the perito- neal coat, enlarged and full of a brownish mucus, the evacuation of which is prevented by the constriction (Fig. 7). The veins are invariably en- Fio. 7. — Abscission of both the right and left lobe of the liver, with enlargement of the bile dncts and of the veins below the tight-lace fissure. larged. The margins of the detached portion are rounded and nodulated (Figs. 6 and 8), and its tissue feels firmer, and exhibits a finely-granular Voi.1.— 3 34 A CLIlSriOAL TREATISE appearance, similar to that which we find throughout the entire organ, when there is an obstruction to the circulation of the blood in consequence of disease of the heart. In this way there is produced a movable nodulated tumor in the situ- ation of the right lobe of the liver which feels hard and nodulated, and may hence be easily mistaken for a new growth. A smaller tumor, which may be grasped in the fingers, may also be developed upon the left lobe. The possibility of an error in diagnosis, arising under such circumstances, is still farther increased by the fact, that the situation and position of the entire organ are almost always altered in various manners at the same time. Fio 8. — Abscission of the right and left lobes of the liver ; a section Is made showing enlarged vessels in the tight-lace conBtriction. 2. Abnormal Positions of the Liver. By abnormal positions we understand deviations from the normal direc- tion of that axis of the liver, which extends from the anterior sharp mar- gin to the middle of the posterior rounded border. This may incline very much downwards, in which case, a large portion of the convex surface of the organ is opposed to the abdominal parietes, and the liver appears larger; it may, on the other liand, be elevated to such a degree that the sharp anterior margin alone remains opposed to the abdominal wall, and thus the extent of surface yielding a dull percussion sound is reduced to a minimum. The li/jamentum j^ensorium hepatis restricts the movement of tlie liver only in cases of enlargement; as Hyrte justly remarks, this is not to be regarded as tlie true supporter of the liver. There are various causes which give rise to these abnormal positions. Sometimes they are the result of mechanical force acting upon the organ from above, or from below; at other times they result from disease, fol- lowed by softening of the hepatic tissue. In many cases, there is simply change in position of the organ; but more generally, along with this there is dislocation. ON DISEASES OF THE LIVER. 35 One frequent cause of abnormal positions of the liver is tight-lacing, the operation of which varies according to the part of the gland which 13 subjected to compression. When the middle or lower portion of the liver suffers from the circular compression of stays, or more commonly of the petticoat strings, the axis of the organ falls downwards, and the edge of the right lobe protrudes far below the margin of the ribs, so that some- times it may be felt in the region of the caecum close to the crest of the ilium,' The removal of the hepatic parenchyma along the groove pro- duced by the tight-lacing, contributes also to the widening of this groove. When the groove is deep, coils of intestine not unfrequently lie in it, and a round solid tumor may be felt in the right iliac region, separated to all appearances from the liver by a space, yielding on percussion a clear tym- panitic sound. If the left lobe is small, it may remain quite unaffected by the tight-lacing; there may, however, be often found upon its margin a movable rounded detached portion, which can be pushed backwards or for- wards. The upper boundary of the or- gan is either quite unaffected, or may be carried upwards towards the thorax, ow- ing to the application of a constricting force over the upper portion. When, on the other hand, the upper third of the liver, where its substance is of considerable thickness, is compress- ed, the axis is also carried very much downwards, and in most cases the entire oro^an is at the same time drao^oced over towards the middle line. The round lig- ament may then be found opposite the eighth or ninth left costal cartilage, and the middle of the right lobe may corre- spond to the linea alba, or may even lie to the left of this, whilst the left lobe penetrates deeply into the left hypo- chondrium (Fig. 9). Upon examination, a liver of about the normal size is then, to all appearances, remarkably enlarged, from its filling up the entire upper half of the abdominal cavity: even upon 2yost-mortem examination, this may be the first impression, until we vinced of the contrary, by and weighing the organ. When, as at the present day rarely happens, the lacing is made below the liver, or close to its lower edge, the organ is pushed up towards the cavity of the chest, and its upper boundary is elevated one intercostal space or more. are con- measurinsT FrG. 9. — Dislocation of the liver towards the median line from tight-lacing; a depressed furrow on the upper part of the right lobe ; apparent enlargement of the organ. ' Cruveilhier (Livr. 40, pi. I. p. 5) asks the question, how a liver which has been altered in position through the operation of a tight-laced chest, may be distinguished from that which results from inflammatory enlargement ; and assumes that the former may b3 diagnosed from its sharp margin. This is a mistake. The right lobe, which is the only part that comes under observation, has always, as the result of tight-lacing, a nodulated rounded margin. 36 A CLINICAL TREATISE The confusion of the alterations in the situation of the liver just al- luded to, with real enlargements and tumors of the organ, is, after a little practice, easily avoided, inasmuch as, by means of careful palpation, we may detect the depression produced by the lacing; the marks of the pres- sure are also often visible upon the skin. It is not, however, to be sup- posed, that these tight-lacings should always have a remarkable effect upon the arch of the ribs; as soon as the tight articles of clothing are loosened, the depression disappears in a great measure, and is then easily over- looked, unless the pressure exerted has been very great and prolonged. We shall return at greater length hereafter to the diagnosis between the condition of the liver resulting from tight-lacing, and several real diseases of the organ. Under certain circumstances, lateral distortion produces the same ef- fect as stays: tumors also, appearing between the liver and diaphragm (unless they lie very far back), and likewise circumscribed peritoneal ex- udations, &c., compress the organ in a downward direction. The left hole of the liver may, when perfectly healthy, undergo slight alterations in position, which may be a source of error, owing to changes in the condition of the stomach. When this organ is empty, the left lobe is much depressed, whilst it is elevated when the stomach is full. A change in the position of the entire liver in an opposite direction to that above noticed is observed, when large quantities of gas ac- cumulate in the stomach and in- testinal canal, or when from asci- tes, &c., the parts of the intestine which contain air are pushed up- wards against the diaphragm. The anterior margin of the liver is then elevated, so that the surface which is in contact with the abdominal parietes is always reduced in ex- tent. Not unfreqiiently, the ante- rior sharp edge is the only part which remains opposed to the ab- dominal wall. When this is the case, the dull space on percussion diminishes more and more, until it becomes difficult to detect the liver at all at the place where the pul- monary sound passes into that of the intestine. In the mammary and axillary lines, it is often quite impossible to do this, because in these situations the margin is sur- mounted by the distended intes- tines, but in the axillary line, such an occurrence is exceptional. In this state of matters the liver appears considerably diminished, although, in reality, its volume is in no way altered. Hence it is a rule which should never be broken, that diminutions of the hepatic dulness, observed in the course of tympanites or ascites, and accompanied by ele- vation of portions of the bowel containing gas, should only be made use Fio. 10. — Rciircsents the situiition of the parts in a case of acute atro|ihy of the liver. The organ has become folded upon itself : collapsed towards the spine, the space corresponding to it being occupied by folds of intc-tine; a, colon ascen lens ; h, sigmoid flexure: r, jejunum: e who are nne hic ited, we mu.st exorcise great caution, if we wish to receive tru.stworthy answers ; 1 have sometimes received reiDiies in the affirmative, which, upon closer inquiry, have been withdrawn. ON DISEASES OF THE LIVER. Y7 censidered to be produced by a yellow tinging of the cornea, and of the aqueous humor, which had been observed to accompany this symptom.' In opposition to this view, however, J. P. Frank brought forward the fol- lowing considerations: that he had met with a yellow condition of the cornea, without the derangement of vision just alluded to; secondly, that the yellow vision intermits; and lastly, that the same symptom is met with in typhus fever without jaundice. Hence, in addition to the jaundiced color of the membranes and fluids of the eye, Frank blamed a morbid ac- tion of the nerves. The latter has in recent times been usually regarded as the sole exciting cause; first, because this symptom is frequently absent in intense coloring of the tissues of the eye; and secondly, because other derangements of the faculty of vision, such as day- and night-blindness, present themselves under the same conditions as those which give rise to yellow vision. Stokes considers yellow vision as an indication of impend- ing paralysis, and Bamberger observes, that he has only met with it in jaundiced persons who have died of cirrhosis of the liver. The analogous condition, however, which is observed after the use of santonine appears to me to argue in favor of the importance of the accumulation of coloring- matter in the blood, and in the fluids of the eyeballs. Here also, whilst the santonine is being transformed by the alkalies of the blood into a colored modification, all objects in a feeble light appear of a greenish-yel- low color, but this colored vision ceases so soon as the coloring matter is excreted by the kidneys. Elliotson's case of jaundice, in which the yel- low vision was limited to one eye covered with varicose vessels, whilst the other eye saw colors unchanged, might admit of another simpler expla- nation. 4. Retardation of the hearf s action. Very commonly the frequency of the heart's contraction in jaundice falls to a greater or less extent be- low the normal standard, in most cases to 50 or 40 beats, and now and then to still fewer; in one case I have counted 28 beats, and in another only 21. This retardation, which not unfrequently is accompanied by irregular rhythm of the heart's action, often lasts for several weeks before it disappears; it ceases immediately, when inflammatory or other acute processes supervene as complications of the jaundice, and a moderate fre- quency becomes substituted. When jaundice appears in the course of anj'' febrile disease, such as acute catarrh of the gastro-intestinal canal, typhus fever, &c., there is, in most cases, a remarkable diminution in the frequency of the pulse as soon as the yellow color shows itself: the pulse sinks from 110 to 80 or 70, or even less. The slow pulse is no constant symptom of jaundice; cases occur in which it remains absent during the entire course of the disease. Why this is so cannot be determined with certainty, any more than we can in general ex- plain the cause of the phenomenon in question. It might be assumed, that the bile exercises an influence upon the vagus nerve, or upon the brain, similar to the action of digitalis; but we do not possess any pos- itive proofs of such an assumption; and the complete integrity of all the remaining functions of the nervous system, as also the condition of respi- ration, renders it very improbable. Whilst along with the diminished frequency of pulse, which follows the use of digitalis, the respiration is ' See Morgagni, Be Sed. et causis morborum, Epist. 37-8; and J. P. Frank, De cu- rnndis hominum morbis, lib. VI.. pars. III., p. 848. Frank's remark that the vitreous humor does not become partly yellow is erroneous ; T have always found more color- ing-matter in it than in the aqueous humor. 78 A CLINICAL TREATISE wont to become more frequent; in Jaundice, on the other hand, the fre- quency of respiration diminishes along with that of the pulse, although not in the same ratio. The number of respirations in proportion to the beats of the pulse is in most cases as 1 to 3. It is conceivable, that the stimulating action of the blood upon the mixscular tissue of the heart may be diminished, or that there may be adhesion of the blood to the coats of the vessels, but at present it is impossible to come to any decision upon the matter. 5. The temperature in simple jaundice remains unchanged. It varies in the axilla from 36.8° to 37.25^ cent. (98.24° to 98.85° Fahr.); such a temperature we find in individuals who have been suffering for a long pe- riod from carcinoma of the liver, or from other organic diseases. It is ob- vious, that the circumstances are different in the cases of febrile jaundice; in catarrhal jaundice with fever, we have found the temperature 38.5°, &c. (101.3° Fahr., &c.) 6. Derangements of digestion. The functions of the stomach in jaun- diced persons are usually unaffected; the patients may have a clean tongue, and may enjoy an appetite which leaves nothing to be desired. We meet first with abnormal conditions of those processes, which go on in the intestine, and which are known to depend upon the deficiency or absence of bile in that tube.' Observations made by establishing biliary fistultr, which, in recent times, have so frequently been repeated, have cer- tainly proved that the absence of the hepatic secretion in the intestine produces no derangements of nutrition by any means remarkable, or threat- ening life; that, on the contrary, most of the objects of chylification can be attained without the presence of bile; still, however, there arises a series of abnormal conditions, the influence of which gradually increases, and, in jaundice of long standing, terminates in defective nutrition. The stoppage to the flow of bile first interferes with the processes of diffusion which take place in the upper part of the intestinal canal, be- tween the fluid portion of the chyme and the blood in the interior of the vessels. It must be of some consequence to these processes, whether or not in the space of twenty-four hours 1 kilogramme (2.204:0 lbs. avoir.) of fluid, more or less, is mixed with the intestinal contents. The want of bile of course does not influence in any remarkable man- ner the digestion of the albuminous and carbonaceous ingredients of the food; but according to the experiments of all practical inquirers upon this subject, the absorption of fat is considerabh' restricted. Jaundiced per- sons have in general an aversion to fatty articles of food, and after eating them a large proportion of the fat appears in the evacuations. The loss in nutrition, which results from this cause, is sufficiently great to become ob- servable in the course of time. Another result of less moment is the loss of the antiseptic influence of the Vjile, Avhich permits of abnormal transfor- mations of the intestinal contents, and the generation of large quantities of gas. Hence, flatulence is generally complained of by jaundiced patients, especially when they exhibit a preference for animal food; in such cases the fa'cal matters emit a putrid odor, they differ greatly from the normal evacuations, and they contain numerous vibriones, and substances which in their chemical characters resemble those which are found in putrefying albumen and caseine. AVhen, on the other hand, the food consists prin- cipally of vegetable, amylaceous substances, the evacuations have in gen- ' Soniftimes the appetite is morbidly increased, and there is a craving for peculiar articles of diet, such as shellfish, mussels, Ac, as in a case observed by Budd. ON DISEASES OF THE LIVER. 79 eral no remarkable odor, and are of an acid nature, because a part of the carbonaceous food undergoes acid fermentation' in its transit through the intestinal canal. This, however, likewise occurs in healthy conditions, so that it might be difficult to determine whether it is increased in propor- tion by the removal of the bile. Of greater importance in a practical sense are the changes in color ■which the freces are wont to exhibit in jaundice, because from their characters we can most easily draw a conclusion as to the more or less com- plete exclusion of bile from the intestine. When the obstruction of the biliary ducts is complete, every trace of bile-pigment disappears from the stools; ' they assume an ash- or clay -color, which only varies according to the nature of the food. Their consistence is almost always at the same time increased; they become hard and firm; the bowels are also sluggish and require stimulation by means of purgatives. This tendency to con- stipation is so constant in jaundice, that the assumption appears complete- ly justified that it is owing to the want of bile in the bowel. Whether the bile favors evacuation by stimulating the peristaltic motions of the in- testine, or by increasing the secretion of the intestinal glands, or by lique- fying the ingesta, are questions which we may leave undecided. Sponta- neous diarrhoea in jaundice is of rare occurrence; I have observed it repeatedly as a consequence of dysentery, which now and then makes its appearance in the course of the disease. More frequently we find, that notwithstanding the exclusion of the bile from the bowel, the stools come gradually to be passed regularly.^ The characters of the faeces are not always such as have just been described. The color certainly often appears paler than usual, but still the pigment is not entirely wanting. This is always the case, when the exclusion of the bile is incomplete, whether this be owing to only a portion of the biliary ducts being compressed, or be- cause there is merely constriction of the principal duct, which impedes, but does not completely arrest, the passage of the bile. The former con- dition frequently happens in cirrhosis, whore the extreme ramifications of the biliary ducts are partiall}^ obliterated by the compression of the new- ly-developed areolar tissue; also in carcinoma and other tumors which are wont to encroach upon certain of the larger branches only; the latter con- dition again is observed in catarrh of the ductus choledochus and ductus hepaticus, in which the tumefaction of the mucous membrane entails only an impediment to the flow of bile, in angular concretions, which cannot completely obstruct the flow, &c. Occasionally we find jaundiced persons passing stools of a normal color, or unusually dark. There may be two reasons for this. Either the cause of the biliary obstruction has been suddenly removed, and the bile passes again into the bowel, whilst the color of the skin remains unchanged, as often happens in the case of concretions, and other rapidly-disappear- ing causes of obstruction; or, there is a sudden cessation of an excessive absorption of bile {Polycholia), of which we shall subsequently speak. * Monro and Pringle long ago remarked the sour smell of the faecal matters. ' Osborne (Dublin Journal^ February, 1858) supposes that the mucous membrane of the intestine can secrete dark bile, like the external integument and the kidneys, and that in this way the faeces may become colored, notwithstanding the closure of the bile ducts. This, as far as my experience goes, is never the case, ^ Graves and Stokes. Dublin Hosp. Reports, Vol. V., p. 109. 80 A CLINICAL TREATISE 4. Duration of Jaundice. The duration of jaundice is very various; it may fluctuate between a few days and several years. The determination of the longer or shorter duration of the disease depends principally upon its primary causes, the persistence of which may vary, and which may of themselves help to bring about a fatal termination speedily or slowly. If we except those forms, in which the other consequences which may result from the primary ex- citing cause of the jaundice, decide the matter, the jaundice which pro- ceeds from simple obstruction to the flow of bile, as when the ductus choledochus is obliterated, may last for years before it terminates fatally. Graves and Stokes ' mention two cases of jaundice, in one of which the disease lasted for eleven months, and in the other for two years, before the nutrition became impaired; Budd ' saw a man who, during an attack of jaundice which lasted four years, with complete obstruction of bile, continued well nourished; Deway" has described a case of seven years' duration, and Van Swieten * mentions the case of a female who suffered from jaundice for eleven years, and was ultimately cured by solvent ex- tracts. The cases which I have had an opportunity of observing, have termi- nated much more rapidly, even when the primary causes of the jaundice have not contributed in any other way to the acceleration of the fatal termination of the disease. Thus, one woman with obliteration of the ductus choledochus died eight months after the commencement of the jaundice; another died after six months and fourteen days; one man with a cancerous tumor of the duodenum, the size of a walnut, only survived the first appearance of jaundice nine weeks. In one case only, in which a biliary concretion had closed up the ductus choledochus, did the jaun- dice persist for two years and a quarter. 5. Modes of Termination of Jaundice. Tlve jaundice does not disappear completely until some time after the removal of the causes wliich have occasioned tlie accumulation of coloring- matter in the blood. Where the cause of the jaundice consists in an ob- struction to the passage of bile into the intestine, the recovery is announced by a return of color to the stools; their color becomes darker by degrees when the disappearance of the obstruction is gradual, as in catarrh of the bile ducts; or they are rapidlv overcharjred with bile, when from the sud- den removal of the obstruction, the pent-up secretion of the liver at once finds its way into the bowel, as in the case of concretions, &c. At the same time, the pigment begins to disappear from those parts which, under normal circumstances, are free from it. First, it disappears from the blood and from the urine; the solid tissues remain colored for a longer period, and particularly those tissues in which the molecular changes take place slowly. Tiie coloring-matter deposited in the epidermal layer of the skin disa})pears gradually as this layer becomes regenerated by desquamation ' Dublin Hospital Reports, Vol. V., p. 103. - 0;). cit. p. oTl. = Gazette ir.ed. de Paris. 1843. •• Comment. III., p. 130. ON DISEASES OP THE LIVEE. 81 and new formation ; hence, it may last for weeks, especially in old per- sons. The coloring-matter appears to be gradually washed out from the other tissues by the current of the nutritious fluid. Thus the complete removal of the jaundiced color always occurs much later than the cessa- tion of the disease, — a fact which must not be lost sight of in the appli- cation of remedies. Not unfrequently jaundice terminates in death, which may be brought about in very various ways. Passing over the influences which the mani- fold exciting causes of jaundice may, directly or indirectly, exercise in this direction (and indeed the mode of fatal termination is as varying as the etiology of the disease, and in most cases death terminates the process sooner or later), we confine ourselves, for the present, to the consideration of those injurious ef- fects by means of which the simple retention of bile may gradually un- dermine the constitu- tion, and lead to death. The accumulation of bile in the blood is fol- lowed by no dangerous consequences; it is only in rare cases that the de- posit of pigment in the parenchyma of the kid- neys impairs the func- tions of these organs to an alarming- des-ree.' The danger to be appre- hended almost always proceeds from the con- secutive changes in the liver itself which result from the retention of bile. The pent-up secretion gradually distends to a greater or less degree the biliary ducts as far as their finest ramifications; stretching through the parenchyma may be seen the cylindrical, or not unfrequently, ampulliform ducts, which compress the adjacent glandular tissue, and a part of the ultimate ramifications of the portal vein. (Fig. 19.) When we make a fine section of the hardened substance of such a liver, and examine it with a moderate magnifying power, numerous deficiencies are seen through- out its tissue, usually situated at the periphery, but sometimes near the centre of the lobules, and here and there forming large empty spaces. (Fig. 20.) The walls of these distended ducts are in most cases considerably thickened. Their contents in general consist of a thin fluid bile, which is mixed with a varying quantity of the mucous secretion of the bile ducts. Occasionally it happens, that the bile is thickened and lines the inner sur- face of the enlarged ducts in the form of a solid, tubular, dark-brown mould. I have seen this in one case, in which there was an exul^erant cancerous growth upon the mucous membrane of the bile ducts; and StoU long ago recorded an instance of a similar nature. Sometimes, notwithstanding Fia. 19. — Enlargement of the bile ducts, and of the pancreatic duct, in consequence of a cancerous tumor in the head of the pan- creas. The details of the case from which the preparation was ob- tained will be afterwards given under Observation Ho. VII. ' Deway {Gaz. med. de Paris. 1843) observed complete suppression of the urinary secretion in a case of intense jaundice, during the last three days of life. See further. Observation No. VI. Vol. L— 6 82 A CLINICAL TREATISE intense jaundice of the liver and other tissues, there is not a trace of bile in the fluid distending the gall-bladder and the excretory ducts. This consists of a colorless transparent liquid, containing a small quantity of mucus along with grayish flocculi and mucous corpuscles. (See Observa- tion VI.) Simultaneously with the distention of the bile ducts, a large propor- tion of the hepatic parenchyma becomes atrophied and destroyed in the manner just mentioned; and another portion is rendered incapable of per- forming its function owing to the accumulation of bile within the cells. In this way, the secreting powers of the gland are more and more im- paired, and the circulation of the blood in it is obstructed. In some cases, the function of the liver is completely arrested, owing to the glandular cells crumbling down into a finely granular debris, in a similar manner to what is observed in acute atrophy. This last change appears to be brought Fig. 21).— a thin .=;pction of thf liver roprosonted in Fig. 10. magnified SO diameters. The large empty epace.^ r.ro the section? of the enlarged bile ducts, the walls of which are n-presciued a.s much thickened. The smaller oiienings, sr.rrouiided liy dark spaces, are the sectinns of rhe hepatic vein.s, surrounbid. ), and Gnersant {Diet, de Med. , Vers Inteft.'). record ob.'ieivations of round worms in the bile-ducts-, still, i: does not appear that jmmdico was invariably present in these cases. ^ Op. cit. * Job van Meckren records a case in which the bile-ducts were closed by the pres- sure of an intussusception. Stokes (Discasefi of the Heart, p. G38) mentions another, in which it was obstructed by an aneurism of the hepatic artery. ' Philosoph Transac.,'Yol. XXYII. 92 A CLESriCAL TREATISE Swieten eight pints of black bile, accumulated in the gall-bladder. Upon careful examination, the smooth pear-shaped tumor of the bladder pro- jecting beyond the margin of the liver is in general easily felt; in a few cases, it may be seen as a prominent tumor.' The increase in the volume of the liver and of the gall-bladder usually goes on for some months; it then comes to a stand-still, and there ensues a more and more observable diminution. This is a proof that the secreting function of the gland is impaired. At the same time unequivocal symp- toms of deranged nutrition, and of obstructed portal circulation manifest themselves, the patients become flabby and thin, the digestion is embar- rassed, water collects in the abdominal cavity, and sometimes haemor- rhages from the stomach and bowels occur. A fatal termination usually ensues, from the gradually increasing exhaustion^ or from general dropsy, or from consecutive exudation processes; less frequently it takes place suddenly by peritonitis consequent upon perforation, and extravasation of bile; or death may take place under symptoms of suppurative fever, in- duced by suppuration of the liver. In some cases, the complete destruc- tion of the hepatic functions leads to cholEemic intoxication. c. Constriction, or Obstruction of the Bile Ducts within the Liver. It is from the presence of one or other of these conditions that jaun- dice becomes a frequent symptom of hepatic diseases. All morbid altera- tions of the liver, rendering the larger branches of the excretory ducts impermeable, such as cancer, echinococci, inflammatory deposits, &c., in- duce jaundice, which is always greater in intensity the more extensive the volume of the liver, and the greater the number of ducts which are impli- cated. Hence tumors or inflammations on the concave surface of the organ are usually accompanied by jaundice, which is generally wanting when these same lesions have their seat on the convex portion, or in the poste- rior part of the right lobe. It is seldom that the bile is in this way com- pletely excluded from tlie intestinal tube, in cases where the new growth, or the inflainmatorv deposit, does not implicate the hepatic duct; the faeces almost invariably exiiibit an admixture of bile. It is worthy of notice that the jaundice which arises in this way, although there is no corresponding variation in its generating cause, varies in intensity at dif- ferent times, according to the variations produced upon the bulk of the tumor, as well as upon the secreting functions of the liver, and the com- pensating functions of the kidneys, by the changes in the quantity of blood supplied in these parts. This circumstance must not mislead our diagnosis, which, indeed, is seldom difficult, inasmuch as, in most cases, the situation of the tumor can be detected by palpation. The jaundice which is produced by the compression of the bile ducts near their origin isoxtremelv slight. This form is now and then observed as an accompaniment of cirrhosis. Under such circumstances, the results of an obstruction to tlie excretion are usually limited to a more or less in- tense jaundice of the hepatic parenchyma, the color of the skin, conjunc- ' I am at presient attendincj a lady whose g-all -bladder reaches downwards to l-J- inch below the crest of ilie ilium, and elevates the abdominal wall in the form of a pear-sliaped tumor. Owinj,' to tlie great tension and pain which it occasioned, it be- came necessiuy to pnnciure it ; and, from the presence of adhesions, tliere was no danger in effecting this. About ten ounces of bile flowed out. ON DISEASES OF THE LIVER. 93 tiva, and urine remaining unchanged. In many cases, however, there may be observed a light-yellow tinge of the conjunctiva, and a darker color around the eyes, while brownish spots may be seen at the angles of the mouth, upon the forehead, on the temples, and on the other parts of the body; at a later period, the pale skin assumes throughout a yellowish color. The stools are sometimes clay-colored, sometimes brown, and there may be often seen in the evacuations dark normally-colored masses, mixed up with others which are pale and free from bile. Sometimes the urine contains pigment; at other times it does not. The expansion of the hepatic cells in fatty liver operates in obstruct- ing the excretion of bile in a similar manner to that in which the areolar tissue acts in cirrhosis; but it is rare for general jaundice to result in the former case. A similar result arises from considerable congestions of the liver, as happens when there is obstruction to the circulation in con- sequence of disease of the heart, lateral distortion of the chest, &c., the origins of the bile ducts being then compressed by the enlarged capil- laries. The jaundice, in most cases of this nature, is limited to a light- yellow tinge of the conjunctiva and skin, and becomes more distinct after violent attacks of dyspnoea. The yellow color is easily overlooked when there is a florid or livid complexion. {^Icterus plethoricus of the ancients.)' The following observations may be given here as illustrations of the points just discussed: — Observation No. V. Dyspepsia. — Symptoms of Chronic Simple Ulcer of the Stomach. — Jaun- dice. — Distention of the Gall-bladder. — Pleurisy of the right side. — Dropsy. — Petechice. — Death. Cancer of the Duodenum and Dilatation of the Bile Ducts — Simple Ulcer of the StomoAih. — Exudation in the Right Pleicral Cavity. Marianne Dombrowsky, a female servant, aged 62, was admitted on December 13, 1853. The patient had been complaining for a year of pains in the epigastrium, which occurred after eating, and were accom- panied by heartburn, nausea, and sometimes even vomiting; subsequent- ly, the appetite had completely failed, whilst the pains had extended over the hepatic region. Four weeks before, jaundice of the skin had gradu- ally become developed. On admission, the patient was emaciated, her skin was dry and flabby, and tinged yellow to a considerable degree. The thoracic organs exhibi- ted nothing abnormal, with the exception of well-marked emphysema of the lungs, especially of the right one. The abdomen was soft, and some portions of the bowel were distended and tympanitic. The liver was deeply situated; its upper border close to the sternum was on a level with the seventh rib; the outline of the organ was somewhat increased; its ' Stokes [Diseases of the Hearty p. 206) has observed repeated attacks of jaundice and hemiplegia to result from incompetence of the mitral valves, these symptoms on each occasion disappearing at the expiration of one day, under the use of stimulants. Not unfrequently the jaundice, in cases of disease of the heart, ia the consequence of catarrh of the duodenum, and then it is of longer duration. 94 A CLINICAL TREATISE dulness on percussion, in the sternal line amounted to 12 centimetres; in the mammary, to 15; and in the axillary, to 13. (4f, 6, 5^ Eng. inches.) Close to the umbilicus, on the right side, and two centimetres [^ inch) from the surface, there might be felt a rounded, painful tumor, which sank downwards upon a deep inspiration, and could be traced upwards as high as the sharp margin of the liver. The upper and under surfaces of the liver, so far as could be made out by palpation, felt smooth and even. No hard tumor could be detected either upon the liver or in the direction of the ductus choledochus as far as the duodeno-pyloric region, even after repeated and careful examinations, with the abdominal parietes relaxed, and with the patient in different positions. The spleen was somewhat enlarged. The stools were clay-colored and smelt badly. The urine was colored brown like porter, and when spread out in thin layers, was saffron-yellow. The pulse was GO and weak. There was no itchiness of the skin. The patient was ordered infusion of rhubarb with the watery extract of nux vomica, and ethereal tincture of valerian. The appetite improved, the pains during digestion, as also the flatulence, were diminished, the motions became regular, but the stools still remained free from bile-pig- ment. The distended gall-bladder increased in size, but continued smooth, painful and movable. Three weeks after admission, dulness on percussion and absence of the respiratory murmur were detected at the base of the right lung, and ex- tending upwards as high as the fourth rib; at the same time, the bronchial tubes were observed to become loaded with mucus, the respiration be- came more frequent, and the patient began to complain of dyspnoea, and expectorated with difficulty rounded masses of tenacious mucus. The pulse rose from 80 to 85. The urinary secretion was diminished. Decoction of senega and liquor anunoniaci anis.' were prescribed. A turpentine liniment was ordered to be rubbed over the thorax and abdo- men; and in the evening, two grains of the watery extract of aloes were administered, to open the bowels. The patient became rapidly collapsed; oedema appeared in the feet, and in a few days extended to the pelvis. The abdomen became fluctuating and tender upon pressure. The pulse was small, and 110 in the minute. On the 26th of January she lost her consciousness, the stools were passed involuntarily, and there were hiccup, dilated pupils, and stertorous respiration. Numerous petechi;T3, varying in size from that of a lentil to that of a groschen -piece, made their appearance upon the skin of the trunk and extremities. Death supervened on the 27th, at 9 A. M. AntopsT/, 2G hotirs after death The skull cap and dura mater were colored yellow, but otherwise nor- mal; there was a small quantity of coagulated blood in the longitudinal sinus. The arachnoid, together with the longitudinal sinus, was consid- erably thickened. The pia mater was of a blood red color. There was a considerable quantity of clear yellow serum at the base of the skull and in ' The Liquor Ammoniaci nnif^nUiK of the Prussian Pharmacopoeia contains recti fied spirit (:!2 parts), liquor ammonias (8 parts), and anise oil yl part). — TR.\NSIi. '' A silver . prepared from the herb and root of the Gratiola officinalis^ Dr Hedge -hyssop. — Ti{AX:^l. ■ The sputa were always free from bile-pigment. They were frequently tested with nitric acid ; but no play of colors could ever be observed. ■■■ See note, page 194. •* See notes, pages 42 and 88. ON DISEASES OF THE LIVER. 109 The liver extended about three centimeters (1^ inch) beyond the mar- gin of the false ribs; it was somewhat reduced in size. On applying the fingers along the outer surface soft places could be felt, varying in size from that of a pea to that of a hazel-nut, which were somewhat promi- nent, and, upon section, discharged a grayish-yellow fluid (enlarged bile ducts). The serous covering was at some places thickened; and the upper surface of the organ was adherent to the diaphragm by newly-formed bands of areolar tissue. The gall-bladder extended about three inches be- yond the anterior margin; its breadth amounted to If inch. The walls of the gall-bladder were white and thickened from organized exudation, and its posterior surface was connected to the duodenum by cords of areolar tissue; the cystic and hepatic ducts were both enlarged to the extent of an inch in their transverse diameter. Three lines below the place where they joined to form the ductus choledochus, the canal was completely ob- literated; there was here a thick, whitely-striated areolar membrane, which constricted (lit. tied off) the duct from without, and bound it firmly to the neighboring duodenum. The contents of the gall-bladder consisted of a grayish yellow mucus, in which were suspended brownish-black flakes, presenting an amorphous appearance under the microscope — the residuum of decomposed bile-pigment. The fluid yielded no distinct reaction with nitric acid. A similar fluid, but somewhat browner in color, was found in the distended bile ducts of the liver. The distention of these ducts was for the most part of a uniform character; but in several places there could be observed ampuUiform enlargements. The walls of the ducts were thick and rigid; they were enveloped externally by layers of white, areolar tissue, which passed inwards along with them through the hepatic fissure. The hepatic tissue was of firm consistence, and upon its cut-section the lobules appeared of a greenish-brown color at their peripheries, brown- ish-black at their centres. The distribution of the pigment was more minutely examined by making fine sections of the organ after boiling, moistening them with acetic acid, and submitting them to a magnifying power of 80 diameters. The coloring-matter could then be seen to be chiefly accumulated in the vicinity of the central veins of the lobules; the color became gradually paler towards their circumference. Dark brown granules lay scattered throughout the parenchyma, which, when more highly magnified, were found to be hepatic cells deeply impregnated with coloring-matter. In addition to the greatly distended thick-walled bile ducts, round or elongated spaces of a brown color were observed at many places, which I regarded as the cross sections of the smallest excretory ducts filled with stagnating bile. The hepatic cells were everywhere intact. Some of them were pale and softened, but in no way abnormal; but most of them were loaded with bile. This consisted of yellow or brown granules, either isolated or adliering in dense groups, in the interior of the cell; in a few of the cells only was a nucleus visible. Many of the cells contained abundant deposits of spherical, angular, or cylindrical little masses, of a yellow, brown, or green color. In several, the coloring-matter was dis- tributed in a uniform manner. "Where the nucleus was visible it some- times appeared pale, at other times tinged with green or yellow. The deposits of bile external to the cells were of various forms and tints; most of them were cylindrical, straight, or bent, in some instances ramified, and occasionally furnished with bulging prominences; their color was yellow, brown, ochre, or green. One would have been inclined to have taken these for casts of the most delicate of the bile ducts, had 110 A CLINICAL TREATISE not this supposition been contradicted by the presence of similar forma- tions in the interior of the cells. Along with these elongated forms other deposits were observed, which were rounded, club-shaped or an- gular. These deposits were of tolerable consistence; by compression between two glass plates, they could be split up and crushed to pieces. Although the substance of the liver was not chemically examined for leucine, until after it had been kept for two days during the warm weather of the month of August, this substance was found in considerable quantity. The spleen was somewhat enlarged, and presented a brownish-red color and firm consistence. The mucous membrane of the gastro-intes- tinal canal was covered with a layer of gray mucus of considerable thick- ness; the mucous membrane itself was for the most part pale, and con- tained but little blood; at certain spots only was it much congested. Nothing abnormal could be detected in the duodenum. The kidneys were of the usual size, their outer surface was smooth, and their parenchyma was of a dirty greenish-yellow color. The epithe- lium of the uriniferous tubes had undergone extensive fatty degeneration, and they were for the most part, especially their nuclei, infiltrated with brown, green, or red pigment. It was only at a few spots, that copious flake-like deposits of coloring-matter could be observed; nowhere did these occur to the extent that was noticed in Case No. VI. It appeared as if these deposits had been removed, or at all events, arrested in their formation, by the use of the highly alkaline Karlsbad water. The bronze-colored skin was subjected to a more minute examination. The pigment was mostly contained in the deepest layer of cells of the rete Malpighi, which were colored brownish-yellow, and contained dark granular deposits. The more superficial layers of cells exhibited only a pale-yellow tinge. The sweat-glands in the axilloe were likewise deeply colored by pig- ment, and contained a large number of molecules and granules, the size of cell nuclei. The cells of the adipose tissue presented a citron-yellow color. The thorax and skull were not allowed to be opened.' The treatment of jaundice from obstruction is always directed chiefly against the cause of the stoppage to the flow of bile, in so far as there is . any prospect of this cause being removed. Catarrh of the bile ducts and of the duodenum, gall-stones, and other mechanical obstructions will after- wards be treated in detail under the heads of each of these diseases. Where the causes are irremovable, we must be guided in the more intense forms of jaundice by the general principles above laid down. In certain incurable organic changes in the structure of the liver, such as cirrhosis, cancer, &c., jaundice of considerable intensity is very often a subordinate symptom, which calls for no special therapeutic treatment. II. Jaundice without atiy detectable mechanical impediment to the excretion of Bile. The pathological origin of the forms of jaundice included under this head is less clear than that of those hitherto dwelt on. We are acquainted ' The microscopic appearances alluded to in the above description are fibred in Plate I. of the colored Atlas.— Traxsl. ON DISEASES OF THE LIVEE. Ill with only two conditions which can give rise to them — abnormal diffusion of bile, arising from some alteration in the supply of blood to the liver, and defective metamorphosis, or impaired consumption of bile in the blood. Both may be present during life, without leaving behind any cer- tain traces of their existence in the dead body. But, even on these sup- positions, it is more difficult and uncertain to form an opinion, and give an explanation of, several of the forms of jaundice belonging to this class, than is the case with the first group; we are obliged to substitute for unequivocal anatomical facts, analogies, the value of which can only be substantiated in a general way, but cannot, by any means, always be proved in detail. Not a trace is found here of those changes in the structure of the liver, which we meet with in the first group in a more or less marked degree, ac- cording to the seat and nature of the obstruction. The bile ducts are either empty or half filled; the hepatic cells, as under normal circumstan- ces, are either free from coloring-matter, or only contain a small quantity; the parenchyma of the gland is at one time anaemic, pale, and soft, at an- other time it contains a normal amount of blood, or is congested; the con- tents of the bowel are found to be mixed with bile. To this class we refer: — A. Jaundice from, Mental Emotions. Physicians have at all times maintained, that jaundice can be produced by functional derangements of the nervous system. It has been thought that it might result from spasm attacking the bile ducts or the muscular tissue of the duodenum, and so producing an obstruction to the passage of the bile. Various considerations, which are opposed to such an expla nation of a stoppage of bile, have already been advanced, quite indepen- dently of the fact, that the jaundice from mental emotions is developed much more rapidly than is ever the case in complete closure of the ductus choledochus. Since Claude Bernard proved, that by irritation of the fourth ventricle of the brain, the sugar formed in the liver can be made to pass off by the urine, the view, — according to which deranged innervation may give rise to jaundice, — cannot be regarded as extraordinary, although the difficulty of explaining the phenomenon is not in this way removed. So far as we at present understand the matter, derangements of the ner- vous functions may lead to accumulations of bile in the blood in two ways: — a. By interruptions to the circulation of blood through the liver, aris- ing from the influence exerted by the nerves over the calibre of the branches of the portal vein. h. By interruptions to the heart's action, the respiratory movements, and the renal secretion. The former of these causes would entail increased formation and ab- sorption of bile; the latter, the existence of which appears to be indicated by the circumstances accompanying the outbreak of the jaundice, would give rise to a diminished metamorphosis of bile (in the blood), or would limit its excretion. At present, we can no more determine which of these two influences is the more powerful, than we are able to do in the case of diabetes. In violent mental emotions induced by vexation, anger, fright, &c., the epigastrium be:jomes suddenly compressed, and there is dyspnoea, a feel- 112 A CLIiaCAL TREATISE ing of suffocation, and sometimes, also, vomiting; the skin becomes pale, and soon after of a jaundiced color, whilst large quantities of urine are se- creted still devoid of color.^ In such a case, the jaundice make its appear- ance in a few hours, and sometimes, as we are informed by authentic ob- servations, in even a still shorter space of time. Villerme ' mentions a case, in which two young persons quarrelled and drew their swords; one of them became suddenly yellow, and the other, terrified at this change of color, dropped his weapon. The same writer relates another case of an abb6 who became suddenly yellow, on a mad dog rushing against him. Although one may be inclined to doubt statements of this nature, still there are numerous observations which prove, that under such circum- stances as those just mentioned, jaundice may be developed in a much shorter space of time than is wont to happen after the application of a ligature to the ductus choledochus. Patients, whose word cannot be doubted, often make communications of this nature, when we inquire into the previous history of their complaint.' Usually, this form of jaundice soon passes off, and is not attended by any further-consequences. But to this there are exceptions; cases are met with in which the disease takes on a malignant character, and in which death ensues after a few days, amid severe nervous symptoms, such as delirium, convulsions, &c. Morgagni, in his thirty-seventh epis- tle, has related cases of this nature, and a similar case is reported by Vil- lerme.^ With the jaundice from mental emotions are closely connected the few observations which we possess of — B. Jaundice from the effects oj Ether and Chloroform. These are interesting, inasmuch as, under the same circumstances, sugar has been observed to pass off by the urine. c. Jaundice from Snake-bites. The jaundice of an intense form may arise after the bite of venomous snakes, is a fact which was known to the ancients. Galen ' relates the case of a slave who became intensely jaundiced after being stung by a viper. Mead ' mentions similar cases, and insists particularly on the rapid- ity with which the yellow color may be developed: "intra non integram horam fit Havus, quasi ejus qui ictero laborat." Under such circumstan- ces, the color often attains a remarkable intensity. Galen and Lanzoni '' make mention of a c;reen tinoreinsr, and Portal ' records the case of an ' This limited excretion of tlie coloring-matter in the urine is not without some in- fluence upon the rapid increase of the jaundice of the skin. - Diet, des Scienc. medic. Art. Icterui^, p. 420. ^ One must be very careful in coming to a decision in such cases. There are coun- tries in which the popular belief that jaundice depend.^ on mental emotions is so strong, that almost every case is attributed to that cause. ■* See chapter on Acute Atrophy of tJie Liver. ^ De locis affectis. Lib. V.. cap. 8. * Teiitamen de vipera, p !jG. ' Tractat. de veneu., cap. V. « Ojh cit., p. 14U. ON DISEASES OF THE LIVER. 113 apothecary known to him whose skin, in consequence of a sting from a viper, became first yellow and subsequently greenish. Results similar to those supervening upon the sting of a viper have been observed after the bites of rattlesnakes {Moseley), of scorpions, and of mad animals {^Bartho- lin). The older physicians attributed the production of this form of jaundice to a spasm of the bile-ducts, or, as Fontana ' did, to a liquefaction of the bile resulting from putrid decomposition. More detailed observations are still wanting to enable us to solve this question. That no obstruction to the flow of bile exists, is proved by the bilious character of the evacuations, both by vomiting and by stool. Still we are uncertain whether the cause of the accumulation of bile in the blood depends upon metamorphoses of a morbid character in the blood it- self, or on a deranged innervation acting upon the circulation and respira- tion, in a manner similar to that which occurs in jaundice arising from mental emotions. In reference to this, the observations made by CI. Ber- nard as to the action of Curari, are worthy of notice. The administration of this poison was found to give rise to congestion of the liver, and to the excretion of sugar in the urine. D. Jaundice from Pycemic Infection of the JBlood. Marechal * was the first to observe that in individuals, in whose bowels pus exists, the skin and conjunctiva, as well as the various tissues of the body, exhibit a more or less marked yellow color. Sometimes there Avas associated with this symptom some anatomical change of the liver, burt more frequently no such alteration existed, even when the color was most in- tense; hence, the appearance was attributed to the dissemination of pus through the tissues. Since then, this yellow color has been recognized as by no means a constant, but still a frequent, symptom of pyaemia, and it has been ascribed, at one time, to the transformation of the coloring-mat- ter of the blood into yellow pigment, and at another time has been re- garded as jaundice, dependent upon an accumulation in the blood of the colorinpr-Tnatter of the bile. Berard * believed that this color could not proceed from bile, because the eyes and the urine were not tinged; and his statements, although erroneous, have been frequently repeated bv recent writers. There can be no doubt that the yellow color arises from the brown matter of the bile, and in every respect agrees with that of jaundice; unmistakable proofs of this opinion are furnished by the bloody the exudations and the urine. In general, the urine exhibits, upon test- ing, distinct indications of the presence of bile-pigment, as do likewise the serum of the blood, and the effusions into the serous cavities. Moreover, we can obtain from the blood the same crystalline coloring-matter as in the blood of patients who have become jaundiced from occlusion of the bile ducts. The anatomical characters of the liver throw no light upon the mode of origin of this form of jaundice; the bile ducts are open and usually pour out a little thin secretion; the organ itself is in most cases anaemic ' Abhandlung iiber das Yiperngift. Berlin, 1787, S. 417. * Recherches sur certaines alterations, qui se developpent an sein des principaux visceres a la suite des blessures ou des operations. These de Paris, 1828. 3 Dictionu. de Med., T. XXVI., p. 491. 114 A CLINICAL TEEATISE and dry; and throughout its parenchyma products are found which indi- cate morbid conditions of the secretion, and of the metamorphoses of mat- ter. To all appearances the jaundice is here the result of an impaired consumption of bUe in the blood, arising from an abnormal condition of the metamorphic processes which go on in that fluid. I annex two cases of pyaemic jaundice, the former of which is simple in its nature, but the second is interesting in many points of view. Obseevation No. IX. Contusion of the pelvic hones. — Rigors. — Somnolence. — Jaundice. — Al- huininuria. — Death. — Phlebitis of the Pelvic veins. — Metastatic de- posits i?i the lungs. — Soft anaemic liver. Gottfried Wiesner, aged 28, on June 29, 1854, suffered a contusion of the pelvic bones from a beam falling upon him. Retention of urine took place, which rendered it necessary to pass a catheter. Above the left pubes there was a superficial extravasation of blood; the power of pro- gression was impaired; but no mobility of the pelvic bones could be made out. All these complaints disappeared, and the patient wished to leave the Hospital, when, on the 8th of July, ten days after the injury, a severe rig- or set in, followed by heat and some sv>'eating. This did not return, but the patient was roused with difficulty, coughed, had some diarrhoea, and became very feverish. On the 11th he was removed to the medical Clinique. Pulse 120. Respirations 32, and accompanied by visible movements of the scaleni muscles; speech indistinct; skin hot and dry; no pain upon pressure of the injured place, and no crepitation; stools pale and thin; urine al- buminous. In the lungs extensive wheezing, and posteriorly, rales could be heard; but no dulness could be made out upon percussion. Ke was ordered decoction of senega root. On the loth, respirations 40 and panting. Pulse 120; heart's sounds clear; profuse perspiration; the conjunctiva and the angles of the mouth had assumed a yellow color, which was rapidly increasing in intensity. Spleen enlarged; thin, involuntar}' stools; urine contained a c[uantity of bile-pigment. On the llth, the jaundice had increased; the pulse was irregular; drowsiness; cedematous swelling of the lower extremities. Died at one o'clock on the following morning. Autopsy. Nothing abnormal in the cranial cavity. The mucous membrane of the bronchi was vividly injected; over the surfaces of both lungs there were numerous patches of collapsed tissue, and sub-pleural ecchymoses. The pulmonary tissue was oedematous and congested; at the lower margin of the left lung there was found a dark- red mass the size of a walnut, with a yellow softened centre; there was a simihir mass in the apex of the right lung; the lower lobe of the right lun^- also contained numerous masses of the size of a cherry, furnished witli yellow centres. On tracing the branches of the pulmonary artery, ON DISEASES OF THE LIVER. 115 granular coagula, furnished with white points, were found in those which were nearest to the masses just mentioned; the lining membrane of the vessel was smooth, and a yellow color could be seen through it, which was due to the presence of pus in the cellular sheath. The heart, stomach, and intestinal canal were normal; the spleen was large and soft. The liver was large, abnormally soft (miirbe), anasmic and flabby; the cells were loaded with finely-granular contents, and some of them with oil globules. The bile in the gall-bladder was scanty, pale, and liquid. The kidneys were soft and anasmic; the mucous membrane of the urinary bladder was covered with ecchymoses; the areolar tissue at the neck of the bladder was infiltrated with extra vasated blood and gelati- nous exudations; and on making a section through this part, numerous veins with thickened walls, and filled with pus, were seen on the cut sur- face; the hypogastric and iliac veins contained granular (krilmliche) coagula. The horizontal ramus of the pubes was comminuted, and the loose fragments of bone lay in an ichorous fluid; the descending ramus of the pubes on both sides was broken. The parenchyma of the liver contained a considerable quantity of leucine; in the blood of the right ventricle there was found 1.17 per cent, of fat, rich in cholesterine; besides this, there was obtained from the same source a considerable quantity of bile-pigment deposited in the form of rods, grouped together in drusic masses. The urine had a specific gravity of 1012, presented distinctly the re- action of the brown matter of bile, and contained small quantities of leu- cine. Observation No. X. Acute Articidar Hheumatism. — En clocarditis. — Repeated Migors. — Pain- fxd enlargemejit of the Spleen. — Jaundice. — Albuminuria and Hema- turia. — Petechice. — Convulsions. — Coma, and Death. Recent deposits upon the Mitral Valve. — Splenic Infarctions. — Flabby anoimic liver. — Ecchymoses upon the mucous membi'ane of the Intes- tines, Bronchi, iS:c. Rosina Peter, aged 24, a servant-maid, who had already been under treatment in the Hospital for incompetence of the mitral valves, was ad- mitted on the 13th of November, 1856, with symptoms of febrile articu- lar rheumatism. The disease had existed for eight days. The left knee and elbow were swollen and painful. Pulse 108; a loud systolic bruit, heard loudest below the nipple. The urine turbid, loaded with urates, but free from albumen. Profuse sweating. Was ordered colchicum and phosphate of soda. About the 20th, the articular affection and the fever disappeared. On the 22nd, at 4 in the morning, and again at 6 in the evening, there was a severe rigor, which lasted an hour, and was accompanied with great frequency of the pulse, and followed by heat and sweating. The joints remained unaffected; and there was no local pain. On the morning of the 30th, there was afresh rigor; the spleen was enlarged, and had become painful. 116 A CLINICAL TREATISE On the 2nd of December, at 6 in the evening, and on the 3d, at 5 in the morning, there were fresh rigors; the spleen extended beyond the margin of the ribs; there was no local affection; the cardiac bruit stronger than when formerly examined. On the 7th, great distress and uneasiness; splenic and hepatic region very painful. G^ the 8th, 10th, 11th, 12th, 13th, 14th, and 16th, there were violent rigors; after this there were no real shiverings, but the pulse was very variable, fluctuating between 100 and 140 beats; there was great increase of temperature, and likewise greenish vomiting, and acute pains in the spleen. The arteries in the limbs were pervious; and the joints were nor- mal. On the 20th of December, slight jaundice was observed, and bile-pig- ment was found in the urine. She was ordered phosphoric acid. The jaundice increased; the stools became brown; but the volume of the liver remained normal. On the 25th, shivering; pulse 136; great restlessness, impaired consciousness; in the evening, two attacks of con- vulsions. On the 26th, violent convulsive fits of the entire body; loss of con sciousness ; pulse 140 ; petechia? the size of a lentil upon the face and chest; urine bloody and turbid; in the evening death occurred. Autopsy. The dead body was intensely jaundiced, and covered with numerous petechiae; upon the outer surfaces of the cerebrum and cerebellum there lay extensive extravasations of blood, from two to three lines thick, which sank deeply into the sulci; the substance of the brain was anaemic and of normal consistence. The mucous membrane of the bronchi was ecchymosed; both lungs were infiltrated with yellow serum, but without infarctions. There were numerous ecchymoses beneath the epicardium; the muscular tissue of the heart was very pale and abnormally soft [niurhe). The mitral valve was covered with a reddish-brown, dry, friable coagulum, having a thickness, at some places, of five lines; its margin was contracted and thickened; and the chorda? tendinea; adhered so as to form white cartilaginous-look- ing bands. Tlie friable deposit upon the anterior flap extended into the middle of the tissue of the valve, as shown by a transverse section, and it liad no well-defined margin; the intermediate tissue of the valve was loos- enod in its texture, partly transparent and vascular, and partly of a dirty- gray color, with yellowish deposits scattered through it. Tlie spleen was remarkably enlarged, and its capsule covered at some places with recent exudation; its parenchyma was congested, and had numerous infarctions of various dates scattered through it. The most rer-ent of these were of a reddish-brown color; the older ones were gray- ish yellow, and softened in the middle; the largest had a diameter of two and a half inches. In one of the splenic arteries, leading to a diseased spot, there was found a small plug, similar to the deposit upon the mitral valve. The liver appeared large, pale, and soft; its color was pale grayish- yellovv-, without any indication of lobules; its cells were normal, and filled with a mass of granules, and, in some instances, with oil globules. The portal vein contained fluid blood, in which there could be observed, even ON DISEASES OF THE LIVER. 117 with the naked eye, small coagula of a brownish-black, or reddish -yellow color; the altered condition of the coloring-matter presented by these co- agula showed that they were of an old date; little masses of coagulum of a similar character were present in the splenic parenchyma, and in the blood of the splenic vein. The gall-bladder contained a considerable quan- tity of dark viscid bile; the bile ducts were unobstructed. The mucous membrane of the stomach was covered with numerous ecchymoses the size of a lentil. A number of extravasated masses of blood, from one to two lines in thickness, and having an area about equal to the size of a two-thaler piece (crown-piece), lay beneath the mucous membrane of the intestine, as far as the colon; the contents of the bowel were scanty, and colored reddish-brown. The mesenteric glands were normal. The kidneys were covered with ecchymoses; their parenchyma was soft, and a grayish-yellow substance was infiltrated through their cortical substance. The urinary bladder contained bloody urine. To account for the purulent infection of the blood, — the existence of which we were obliged to assume from the symptoms and course of the disease, as also from the anatomical appearances, — no lesion could be found, with the exception of the morbid changes in the mitral valve and in the spleen. Purulent and ichorous deposits and disintegrating thrombi in the interior of the veins were sought for in vain. There could be no doubt that the masses in the spleen depended upon emboli in the arteries, derived from particles which had been swept along from the deposit on the valves of the heart; it was questionable, however, whether the puru- lent infection of the blood arose from the same cause. Virchow ' is of opinion that we cannot entirely deny that symptoms, which closely resemble those of pysemia, may be produced by the corroding {itsurirende) and ulcerating forms of endocarditis; and he records one case, in which he be- lieved such an explanation to be possible; he thinks, however, that accu- rate observations are still wanting to corroborate the theory. Even the case before us cannot be regarded as one to the point, inasmuch as there is as much, if not greater, probability in the assumption that the purulent infection resulted from the deposits in the spleen. The colored coagula in the portal and splenic veins showed that pathological products passed into the blood from the spleen; whether these consisted only of the de- composed red matter of the blood, or whether there were also substances which exerted a chemical action, cannot be determined. Moreover, the course of the disease showed, that the emboli in the splenic artery had existed for a long period without giving rise to any symptoms indicative of blood infection. At the commencement, previous to the rigors, the patient had no bad symptom, and only complained of pain in the enlarged spleen on the eighth day after the first rigor; not until fourteen days after this same rigor, did the train of symptoms which are wont to accompany infection of the blood, make their first appearance. The morbid changes in the heart, from which the unfavorable progress of the case originated, were partly of old, and partly of recent, date. A fresh endocarditis appeared as a complication of the acute rheumatism in the already diseased and incompetent mitral valve; this gave rise to the deposits upon the valve, and subsequently, by means of emboli, to the af- fection of the spleen. ' Gesammelte Abhandl., S. 700 and S. 711. 118 A CLINICAL TEEATISE E. Jaundice from Typhus. Jaundice is usually a symptom of much rarer occurrence, in typhus than in pyaemia: in ileo-typhus ' it is only observed in exceptional cases; but in petechial typhus * it is of frequent occurrence, several epidemics of this affection having been characterized by the frequency of jaundice. The mode of origin of jaundice under such circumstances has not yet been investigated with anything like sufficient care. In many cases, and es- pecially in ileo-typhus, the jaundice appears to be of a catarrhal nature; usually, however, no obstruction to the excretion of bile can be detected, the existence of which is also contra-indicated during life by the fact of the stools being colored. The liver does not present any important alter- ation in its texture; it is in most cases pale, soft, and shrivelled, and has its cells filled with finely -granular contents. I have repeatedly observed yellow or reddish-brown pigment flakes in the blood of the trunk of the portal vein, or of its capillary branches, which appear to proceed from the enlarged spleen, in a similar manner to what has been described in con- nection with pyasmia. (Observation No. X.) In one case, round soft- ened masses were found in the liver, but whether these were produced by emboli or not, could not with certainty be determined. My own opinion is, that the jaundice which accompanies the more severe forms of petechial typhus, must be explained in a manner similar to pya^mic jaundice. The following observations may throw some further light upon the matter. Observation No. XI. Exanthematic Typlxus. — Jaundice. — Alhumimiria. — Uoemorrhage from the hoicels. — jEJcchi/moses of the skin. — Parotitis. — Death on the twelfth day. Small Spleen. — Ancemic Liver. — Kormal hepatic cells. — Unobstructed hile ducts. — Ko disease of the intestine, nor of the Mesenteric glands. J. Fr. Pechhold, aged 55, was l^rought to the Hospital from the Work- house on the 31st day of December, 1855, at a time at which there was admitted from that Institution thirty-one cases of typhus within a period of three days. The patient presented all the symptoms of simple typhus; a widelv-spread exanthem; delirium; pulse 120; respirations 29; consti- pation for three days; urine turbid, free from albumen and bile-pigment. He was ordered castor oil and chlorine-water. On the 2nd of .January, 1856, there was observed a yellow color of the conjunctiva and of the skin of the face, Avhich increased very rapidly; the urine v.as dark brown, and contained an abundance of albumen and bile- pigment ; tiiere was blood in tlie stools; pulse 98; no enlargement of the spleen; the hepatic dulness in the mammary line measured 5^ centimetres (2| English inches); great tympanites; much restlessness and active delir- ium. AVas ordered muriatic acid. On January 3rd, there were extensive ecchymoses of the skin; the ex- ainlicin was paler; two thin bloody stools; pulse T6; a quiet apathetic de- 1 Tho s')-cnlleil Ty]ihoid fever, or the Fi<:i-re typJiulde of Louis. — Tkaxsl. - The true epidemic tyi^hus. — Tr.\:nsl. ON" DISEASES OP THE LIVEK. 119 Eortment; tremors of the extremities; skin dry and dark yellow; the al- umen in the urine diminished in quantity. On the 4th, pulse 68; a thin greenish stool; towards evening, a second stool containing blood; urine pale, free from albumen; jaundice very in- tense; consciousness unimpaired. Was ordered to continue the muriatic acid. On the 5th, a very bloody evacuation, which was followed by great exhaustion; pulse 96, small and weak; hepatic dulness in the mammary- line 3 centimetres [1\ inch), and in the axillary 6 cent. (2f English inches); great apathy and loss of memory. On the 6th, pulse 88; the ecchymoses had increased in extent; bloody stools; urine pale and free from albumen; somnolence. On the 7th, there was developed in the left parotid, a tense, painful tumor of very considerable extent, the lower part of which felt soft, and poured out a bloody serum when punctured with a needle. Pulse 96; skin dry and cool; urine brownish-black, loaded with pigment; free from albumen, but containing much urea, and traces of leucine. Slight cough with bloody sputa; no exudation in the lungs could be detected; som- nolence as before; pupils normal. Was ordered benzoic acid with cam- phor. On the 8th, pulse 108, very small, symptoms of pulmonary oedema; inability to expectorate; tremors of the extremities. Death ensued on the morning of the 10th, after a long agony. Autopsy. Brain and cerebral membranes normal. The mucous membrane of the bronchi covered with a yellow frothy serum; the lungs posteriorly hy- postatic and oedematous. The heart contained a considerable quantity of firmly-coagulated blood; its valvular apparatus and muscular tissue were normal. Spleen small, two and a half inches broad, and four inches long, anae- mic; liver very large, and weighed 1.45 kilogr. (3.196 lbs. avoird.) pale and anaemic; of tolerably firm consistence; the cut surface presented a nut- meg appearance; the gall-bladder contained a small quantity of thin pale bile; the bile ducts unobstructed. The hepatic cells were normal, but loaded with granular contents, and some of them infiltrated with fat. The blood of the portal vein, as also several of the capillaries of the liver contained reddish-brown, and a few black, flakes of pigment. There was no sugar in the hepatic tissue. Leucine was found in large quantity, but no tyrosine. The mucous membrane of the stomach was of a bright-red color; that of the intestine was pale, without any deposit in, or ulceration of, the glands; the fgecal matter in the ctecum was of a green color; the mesen- teric glands were not enlarged; in the rectum were a few hEemorrhagic erosions the size of a linseed. The kidneys were congested, and of a jaundiced hue; the glandular epithelium was partly in a state of fatty degeneration, and partly filled vrith a finely granular substance, which was rendered pale by the action of acetic acid. 120 A CLINICAL TEEATISE Obseevation No. XII. Petechial Typhus. — Jaundice. — Albuminuria. — Suppression of Urine. — JPneumonia on Right Side. — Dysentery. — Death on the seventh day. Lardaceous Spleen of old date. — Ancemia of the Liver. — Exudation into the Might Lung. — Dysentery. — Hecent Exudation in the Kidneys, C. Winzig, aged 37, a day-laborer, was admitted on the 1st of July, 1856, with the symptoms of exanthematic typhus; the patient was covered with an extensive roseolar eruption {Koseola-eruption), inter- spersed with a few petechise; considerable enlargement of the spleen; pulse 110. On the 3rd, a slight jaundiced-tint of the skin was observed, and the urine contained albumen. On the 4th, the patient was brought to the Clinique. Great muscular debility; numerous petechise upon the skin, which was intensely yellow; stools involuntary, very fetid, and containing blood; urine very scanty; only two ounces were drawn off by catheter in 36 hours, and the bottle, which constantly lay beside him, remained empty. Pulse 80, small and weak; respirations 10; extremities cool. Was ordered muriatic acid with spirit of nitric ether. On the 5th, there was dulness over the lower and posterior part of the right side of the chest; feeble bronchial breathing; volume of the liver normal; spleen large; somnolence. Pulse 90; respirations 16. Collapse and cold extremities. Was ordered three grains of musk every hour. On the mornin": of the 6th he died. Autopsy, 12 hours after death. Tlie substance of the brain was somewhat congested; its consistence normal. Bronchi pale; recent exudation and bloody infarctions in the lower lobe of the right lung. The heart contained firmly-coagulated blood; muscular tissue and valves normal. GEsophagus pale; the mucous membrane of the stomach exhibited bloody suffusions, but no ulceration of the surface; the mucous membrane of the jejunum and ileum was pale, that of the cecum and colon con- siderably reddened, and covered with firm brown faecal matter; in the de- scending colon, and reaching down into the rectum there were dysenteric deposits of an advanced stage, but no ulceration. Spleen large and firm, and infiltrated with lardaceous matter. Liver of normal size, of a pale-brown color, and exhibiting here and there isolated yellowish-white anivmic patches; consistence tolerably firm. Bile ducts unol^structed; gall-bladder half-filled with a dark secretion. The lic}iatic colls contained pigment molecules and isolated drops of oil; lardaceous matter, such as existed in the spleen was nowhere to be seen. The clioinicul examination of the organ showed the presence of an unusu- ally large quantity of sugar, besides much leucine, tyrosine, and hypoxan- rl'.inc. It was very reniarkable tliat in the spleen leucine was almost en- ON DISEASES OF THE LIVEB. " 121 tirely absent. This substance could be detected in the thick bile, which also contained crystalline coloring-matter. The kidneys were of a deeply jaundiced hue, considerably congested, and of soft consistence; the glandular epithelium was tinged partly greenish-yellow, and partly dark-brown; some of the tubuli contained cylindrical yellow coagula. Leucine and tyrosine were present in these organs also. The urine collected during the last day of life contained an abundance of pigment, but no traces of albumen. Obskevatiok No XIII. Abdominal Typhits ; a severe rigor during convalescence y a fresh en- largement of the Spleen / great tenderness of the region of the Liver ^ and afterwards of the entire Abdomen, — Jaundice. — Dyspnoea. — Soni' nolence. — Death. Cicatrizing typhous ulcers in the Ileum, ; recent enlargement of the Spleen / round softened masses, of a brown color, and about an inch in diametery in the Diver. — Dile ducts unobstructed. — Peritonitis. Carl Mauche, railway laborer, jet. 26, had been complaining since the 17th January, 1854; he was compelled to seek assistance from the Hospital, on account of painful sensations in the lower half of the right side of the chest, diarrhoea, and great weakness. On his admission, on the 2nd of February, it was ascertained that the patient was laboring under bronchial catarrh; the pulse was 100; the tongue was moist and coated gray; the mental faculties were unimpaired; the spleen appeared to be enlarged in every direction; it extended from the level of the sixth rib downwards to four centimetres (1^ inch) beyond the margin of the eleventh rib. Infusion of ipecacuanha and gum arabio were prescribed. On the 3rd, pulse 96. Roseola. Six thin stools, containing but little bile. Ileo-csecal pain. No delirium. On the 6th, pulse 120, severe cough with viscid sputa; dry, hot skin; tympanitic abdomen; more thin stools. Was ordered chlorine water. On the 9th, pulse 88, and bisferiens; the exanthem had extended over the entire body; no motion of the bowels for two days; the urine deposited an abundance of urates; sputa bloody, without any obvious exudation in the lungs; dulness of hearing; splenic enlargement un- changed. On the 11th, pulse 92; the eruption is fading; castor oil was adminis- tered on account of a sluggish condition of the bowels. On the 13th, pulse 84; the dulness of hearing had ceased; the spleen was reduced in size ; the skin moist, and the appetite had returned. Was ordered infusion of Peruvian bark. On the 15th, the patient was convalescent. On the 18th, it was necessary to administer an infusion of senna, on account of obstinate con- stipation; this brought away solid, feculent, and afterwards pultaceous stools. On the 21st, the patient had a sudden violent rigor, lasting for an hour and a-half, and succeeded by an increased temperature of the skin. 122 A CLINICAL TREATISE and frequency of pulse; the tongue was dry, and there were noises in the ears, great debility, profuse green-colored evacuations from the bowels; the abdomen was tender and distended. Was ordered muriatic acid. On the 23rd, pulse 136, and respirations 36; skin and conjunctiva yel- low; tongue dry; abdomen tender; thin greenish stools, frequent but scanty. The spleen had again increased in volume, extending 5 centime- tres (2 inches) beyond the margin of the ribs. The hepatic region was very painful on percussion, and its dulness in the mammary line amounted to 3 inches. Twelve cupping-glasses were ordered to be applied over the hepatic region. On the 26th, the jaundiced-color had increased; the thin, greenish stools continued, and masses of a greenish-color were repeatedly vomited. The urine was scanty, and tinged with bile. Pulse very small, and scarce- ly perceptible. The tenderness in the hepatic region was increasing, and extended over the entire abdomen; great dyspnoea. On auscultation, widely extended rules were heard, but no consonating phenomena.* Som- nolence. Was ordered benzoic acid with camphor, and warm cataplasms over the lower part of the abdomen. On the 2?th, death supervened under symptoms of pulmonary oedema. Autopsy. The membranes of the brain and the cerebral substance were consid- erably congested ; the latter was of normal consistence. The air-passages in the upper part of the lungs were pale; in the lower part, the mucous membrane of the bronchi was reddened and relaxed; the pulmonary tissue was ctidematous, at some places collapsed, but free from any solid exuda- tion. The mucous membrane of the stomach was pale, with a few isolated ecchymoses. The serous membrane of the intestine was covered with ex- udation, 2:)artly recent and partly breaking down into pus. Some portions of the bowel were glued to one another and to the omentum. In the mu- cous membrane of the ileum a small number of typhous ulcers were found, already exhibiting a perfectly clean surface, and in process of cicatriza- tion; no traces could be detected of recent deposits, to indicate a relapse of the typhus. The mesenteric glands were moderately enlarged. The kidneys were soft and congested. The spleen was remarkably hypertrophied, tense, and elastic; its tis- sue vras soft, pultaceous, and congested; at its anterior border there was a rcddish-broM'n infarction, the size of a walnut. The liver was unusually soft; its surface was smooth and its margins sharp; its sui-faces, on section, appeared of a reddish-brown color; some spots v.'cre darker than the tissue immediately surrounding, and of a soft- er, almost pultaceous consistence. These masses were of a rounded form; measured from 1 to 1^- inch in their transverse diameter, and were sepa- rated from the surrounding more solid tissue by a tolerably sharp line of demarcation. The bile ducts were pervious; and the gall-bladder con- tained a small quantity of tliin pale bile. The firmer portions of the hepatic tissue, on closer examination, pre- sented everywhere normally-formed granular cells. These existed only in small (quantity in the softened portions; here there were chiefly ob- ' r-ronchoi>boiiy. For an account of Skoda's theory of consonance, see Walshe on " Diseases of the Lungs and Heart," 1st Ed., 1851, p. 128. — Transl. ON DISEASES OF THE LIVEK. 128 served finely granular masses, and the debris of disintegrated cells, free nuclei, oil globules, &c. The liver, after exposure to the air, yielded con- siderable deposits of leucine and tyrosine. Unfortunately, the examination of the blood of the portal vein, and that of the branches of this vessel leading to the softened portions of the liver, was neglected in this case; hence, it could not be determined vvhether or not the blood from these sources exhibited abnormal conditions of any importance. It is worthy of notice, that when the infectious diseases just alluded to are complicated with jaundice, a group of severe symptoms, such as hremorrhages from the gastro-intestinal mucous membrane, &c., albuminu- ria, hfematuria, suppression of the urine, &c., manifest themselves in a similar manner to what we find to be the case in yellow fever, and in the severe intermittent, remittent, and recurrent forms of fever, which are pe- culiarly endemic in tropical countries; — a circumstance which would appear to indicate an intimate relation between these morbid processes. The post-mortem appearances which we find under such circumstances, in the forms of fever more common in this country, are enlargements of the spleen and of the hepatic glands, and acute tumefactions of the liver and kidneys; ' the glandular epithelium in the two last organs becomes filled with granular masses, and, at a later stage, with deposits of fat; their se- cretions diminish, and are sometimes suspended, whilst certain products of metamorphosis accumulate in their tissue. In this way the liver participates, more or less actively, in the infec- tious blood-diseases. In typhus, its secreting function is impaired at an early period, the evacuations become pale, and upon post-mortem exam- ination, a gray or greenish-yellow fluid, which, as a general rule, contains leucine, is found in the gall-bladder," The circumstances are similar in the so-called pyaemia, and its allied conditions. The formation of sugar, as well as the elaboration of bile, is diminished, and usually is soon com- pletely arrested; ' at the same time, substances find their way into the secretion of the gland, which, under normal conditions, or in the course of other diseases, are either absent or exist in much more sparing quantity. "We find leucine, and usually also tyrosine in considerable quantity, to- gether with a substance resembling in its characters xanthine and hypo- xanthine, also a peculiar yellow substance in the form of yellow globules, and occasionally, according to Scherer, cystine. The secretion is fre- quently neutral, and contains ammonia. We have examined the liver, for the substances just mentioned, in a large number of diseases, and have arrived at the general result, that in typhus fever, the pyj^^mic or septic infection, the various exanthemata, the malignant intermittents, &c., the substances just mentioned exist in unusual quantity, whereas they are either absent or in very sparing quantity in pneumonia, tubercle, ' Of these three organs,' the spleen appears to be the one which is most frequently and most extensively implicated ; then the liver ; and, lastlj', the kidneys. It is still uncertain whether this depends only upon the intensity of the infection, or upon differ- ent qualifies of the poi«on. In yellow fever the affection of the kidneys is more marked and more constant than that of the spleen. ' There are cases in which a complete suspension of the secretion occurs, followed by all the consequences of acholia. See Observiition Xo. XVIII. ^ It is by no means always suspended. In a third of the cases of typhus, the livei etill contains sugar, the quantity of which is for the most part small, but sometimes considerable. 124 A CLimCAL TREATISE organic diseases of the heart, dysentery, diabetes, &c. It is impossible, in the present state of our knowledge of the metamorphic processes of matter, to understand all the important bearings of these facts, especially as similar products exist at the same time in other organs, such as the spleen, the lymphatic glands, and the kidneys. Still, the indications of local derangements in the metamorphosis of matter induced by the blood in the liver, and in other structures becoming infected, which the presence of these substances furnishes, are of importance. There can be no doubt that these derangements react upon the composition of the blood; the presence in the urine of leucine, the salts of valerianic acid, and some- times, also, of substances similar to xanthine, shows that these derange- ments are not of a limited character, but that their products pass into the blood and the excretions. The pathological importance of these processes, however, cannot be determined with any degree of certainty, until the nature and extent of the implication in the general metamorphosis of matter of the parenchyma of the several organs and tissues, the varying character of which has only been recently investigated, is completely un- tierstood both in health and in disease. In the last described group of varieties of jaundice, we have learnt to recognize this affection as a consequence of impediments to the diffusion, or to the consumption of bile, which are brought about partly by the in- fluence of the nervous system upon the respiration, circulation, and secre- tions, but chiefly by abnormal conditions of the processes of metamor- phosis in the blood. It is only in this point of view that the affection can be regarded as of importance as a symptom, or as an indication for treatment. The treatment has to be directed against the derangements of inner- vation, as well as against the abnormalities of the metamorphic processes upon which the jaundice depends. In cases where the action of these derangements is of a transient nature, as in mental affections, there is seldom any need for interference in the way of treatment; the milder anti- spasmodic stimulants, together with a tranquil deportment, warm baths, &c., are sufficient: when there are symptoms of danger, ether, castoreum, musk, &c., are indicated; and eventually, the measures which are recom- mended under the head of Acute Atrophy of the liver. In cases of snake-bite, purulent infection, typhus fever, and the allied conditions, it is the primary diseases which must be attended to; the jaundice, in itself, demands no especial treatment. r. Bilious Fevers and the Epidemic Forms of Jaundice. This is not the place to describe in detail the various fofms of fever which are complicated with bilious symptoms; the sole question for us to investigate here, is the mode of origin of the jaundice, which makes its appearance under such circumstances, and the influence exerted by the admixture of bile with the blood upon the course and symptoms of the primary disease; and in general terms to explain, so far as reliable materi- als are in our possession, the part played by the liver and its secretion in the morbid processes in question. In ancient pathology, bilious fevers (under which name were included diseases of very diverse character) ' comprised those affections in which ' '• On pent citer conime \\n rare modele de confusion et de savante obscurite la doctriuu des fiuvrt'S dites bilieuses." {Find, Nosograpli. philos.^ T. I., p. 41.) ON DISEASES OF THE LIVER. 125 with disturbance of the vascular system, there were associated yellow color of the skin and conjunctiva, a bitter taste and bilious evacuations either upwards or downwards; — they were thus a very comprehensive class. The climatic and telluric agencies of the country which formed the cradle of our science, as well as of that in which medical science was sub- sequently developed, furnished rich materials for observations bearing upon these diseases. They were referred by the ancients, in accordance with the tenets of a humoral pathology, to a faulty condition of the quan- tity or the quality of the bile, in which fluid, it was believed, the key had been found to explain diseases of the most varying nature. At the close of the seventeenth century, doubts were raised against this, as well as against other Galenic theories. Sydenham was the first who, from obser- vations of the epidemic of 1669-70, ventured to express the view, that bilious evacuations and jaundice often constitute symptoms of only secon- dary importance, which may complicate diseases of very different charac- ters. This first attempt to limit the class of bilious fevers was not followed by great results, inasmuch as the bilious constitution of the eighteenth century, brought not only the mass of physicians, but also such men as Huxham and others, back into the old beaten track. Selle and Stoll were the first to establish the fact of the participation of the mucous mem- branes of the stomach and intestines in the origin of these fevers; but the arbitrary manner in which the latter writer attributed the A-arious phe- nomena of these affections to the metastasis of bile,' was little fitted to favor further progress. Pinel expressed in a more decided manner than any of his predecessors, the opinion that the principal seat of these diseases was to be sought for in the digestive organs, and particularly in the stomach and duodenum. Broussais went a step farther, and declared that these fevers, the idiopathic nature of which he denied, resulted from inflammation of the gastro-intestinal mucous membrane, accompanied b^ an excessive secretion of bile. This view soon became widely extended in Germany, chiefly on the authority of J. P. Frank, it became the cus- tom to regard bilious fevers in general as a degeneration of gastro-enteric catarrh, and jaundice itself as of a catarrhal nature. There was no doubt that this was a one-sided view. Although there can be no question as to the independent existence of these morbid processes, as Littre has re- cently endeavored to prove, still the frequency with which jaundice is met with in these fevers shows that the implication of the liver cannot be looked upon as a merely accidental complication, but that there exists between the two a more intimate connection as regards their mutual ex- citing causes. The nature of this connection can only be learnt by a careful analysis of the observations hitherto made. The descriptions which have been handed down to us by the older writers, are not of much use for this purpose; and little more can be said of the accounts which have been left behind by Tissot,' Stoll,' Finke,* and Pringle, because, as has already been justly observed by Rayer, very different morbid processes were grouped together, and but little attention was paid to their anatomical origin. The best materials are to be found ' Ad encephalura dolata humoris biliformis portio deliria, pliremtides, apoplexias, genns opane convulsionum facit, ad fauces anginam, ad thoracem tussin, pleuritidem, ' TissoT, Dissert, de fehrib. bilios. anomal. seu hiator. epidem. biUos. Lausanne, 1758. ^M. Stoll, Aphorism decognosc, &c. 1797. *L. Finke, Deinorb. bilios. anom. 126 A CLINICAL TREATISE in the works of Annesley,' Boudin,' Haspel/ and especially of Griesin- ger,* upon the diseases of tropical climates, to which may be added, the writings upon yellow fever,' and a portion of the monographs upon the epidemic marsh fever of Holland in the year 1826. Although the febrile processes which are most frequently associated with bilious symptoms differ in many respects from one another, still they have many points in common. They belong, without exception, to the group of infectious diseases {Infectionskrankheiten^ which owe their ori- gin to the absorption into the system of deleterious matters, of miasmata, and partly, also, as appears, of contagions. They are for the most part endemic in the swampy and marshy districts of hot climates, and only make their appearance in colder regions as extensive epidemics, when con- ditions arise particularly favorable to the development of deleterious efflu- via, and to the active operation of these emanations upon the human spe- cies. They commence with changes in the composition of the blood, with which local lesions, especially of the spleen and liver, and often, also, of the kidneys, become associated. The diseases belonging to this class, when they reach an intense degree of severity, give rise to a train of symptoms having many points in common: — jaundice, hfemorrhages from the stomach and bowels, petechife, alarming nervous symptoms, albuminu- ria, suppression of urine, &c. Moreover, in most cases, the fever runs a certain course, and then suddenly ceases, either without returning (yellow fever), or followed by other paroxysms, which sometimes assume a fixed type (intermittent and remittent forms of fever), or at other times, ap- pear as relapses without any fixed type (relapsing fever). But along with these characters in common, there exist important differences, which ne- cessitate a rigid discrimination of the different forms. We observe bilious symptoms as a common accompaniment of, first: — a. Intermittent and Remittent Marsh Fevers^ and especially in those which are met with in tropical countries. The fre- quency with which jaundice makes its appearance under such circumstances varies at different times and places, without our being able to assign any definite cause for such being the case. In Algeria, Boudin sometimes found this symptom present in seven-tenths of the cases of intermittent fever. In colder climates, it is only in exceptional epidemics that bilious sj-mptoms attain a remarkable frequency, as in the epidemic which, in the year 182G, extended along the coast of the North Sea, from the Eider to the Schelde, and in the epidemic which is recorded to have prevailed in 1807 between Mende and Greifswald. The inilucnce which the supervention of bilious symptoms exercises over the course and terminations of fever, has not been sufficiently estab- lished by observation; in general, it does not appear to be of much conse- quence, because almost all the dangerous symptoms which accompany the ' AxxESLEY, Researches into the causes, nature, and treatment of the most prevalent dmascs of India. Vol. II., p. 419. ''BocDix, Trnite des fihres intermittcntes. Paris, 1842. '^Ha^pel. Maladies de VAlgerie. Tom. 11.. p. 151. •'Giui'.sixGEU, Das biliase Typhoid, Archiv f. phys. Heilk. Von Vierordt^ 1853. Heft 1 mid 3. Also, JIandhnch der tipec. Path, und Therajne, redig. ton Virc/iow. 2 Bd. 2 Abth. " Die Infectionskrankhciten^'' of the same author. ^L.vIIoche, Yellow Fever. Philadelphia, 1855. ON DISEASES OF THE LIVER. 127 jaundice may occur without it; it is only where the local changes in the liver attain an advanced stage that they give rise to marked results. Be- sides this, according to the experience of Annesley, the excessive secre- tion of the liver passing into the intestine, may give rise to inflammation of the mucous membrane, dysentery, &c. In addition to the slighter forms, which, under judicious treatment, rapidly subside, severe cases are met with, accompanied by typhoid symptoms and various local affections, in the course of which petechige appear, and haemorrhages occur from the stomach and bowels, and in which the urine contains albumen or blood, or this secretion becomes completely suppressed. Such malignant cases bear a striking resemblance in their symptoms to yellow fever; they dif- fer, however, essentially from that disease in their progress and in their anatomical lesions. The milder forms, for the most part, exhibit the sin- gle or double tertian type, rarely the quotidian or quartan; ' the more se- vere cases, such as those which are accompanied by local derangements, generally appear as remittent or continued fevers. The jaundice does not always arise in the same way; in many of the milder epidemics, the jaundice is produced by some impediment to the ex- cretion of bile, owing to the fever being complicated with severe gastro- duodenal catarrh; in such cases, the bowels are torpid, and the stools are deficieat in bile, and usually there are fundamental lesions of a more pro- found nature. Besides acute enlargement and softening of the spleen, which are often associated with wedge-shaped infarctions, or more fre- quently with abundant deposits of pigment, the liver is usually found to be enlarged from congestion and softened, its blood-vessels are seen to be filled with pigment flakes, and occasionally we observe extravasations of blood or abscesses in the parenchyma of the gland. In other cases, espe- cially such as run a proti"acted course, and are accompanied by copious ha?morrhages from the stomach and bowels, the liver is found to be anre- mic and jaundiced; the bile ducts are usually pervious, the gall-bladder distended, and the contents of the bowels loaded with bile. Quinine, ad- ministered in a suitable manner, exercises a favorable influence over the progress of these affections. Closely allied to the diseases just considered, as regards their anatomi- cal lesions, and the operation of quinine, although in other respects bear- ing a greater resemblance to typhus, is: — b. The Recurrent Fever. {Das recurrirende Fieber — Relapsing Fever — Fihvre d rechute), which is remarkable for the frequency with which it is accompanied by jaundice. This form of fever making its appearance in distinct, regular fits, has only recently been accurately distinguished from typhus and the intermittents, although we possess many observations of an older date as to its prevalence." This is the fever which gave rise to the great epidem- ics which have prevailed in Scotland and in Ireland, and also in London, ' In the quartan type, I have observed the jaundice to intermit : during the apyrex- ial period the color became pale, and grew darker again with the return of the parox- ysm. * See HiLDEiTBKANU, " Ueber den ansteckenden Typhus.'''' Wien, 1815. Lasbet, " Memoires de Ckirurgie miUtaire.'' Paris, 1813. 128 A CLINICAL TREATISE since 1843.' Bilious symptoms, such as jaundice, and biliois evacuations both upwards and downwards, occurred during the first or second par- oxysm ; they varied greatly in frequency ; in certain of the epidemics in Scotland, they were almost of constant occurrence, so that the disease was designated " Mild Yellow Fever ; " in other instances, as in London, Jenner observed these symptoms in only one-fourth of the cases, and oc- casionally they have been observed even less frequently. Of the anatomi- cal lesions, which in general are not very remarkable, swelling of the spleen is the most conspicuous; this not unfrequently becomes excessive, and is accompanied by the formation of infarctions. The liver sometimes becomes tumefied from congestion, and at other times is found soft, pale, and yellow; along with these conditions, the bile ducts are pervious, and the gall-bladder is, in most cases, filled with dark secretion. Here, as in intermittent and remittent fevers, the jaundice is, under certain circum- stances, accompanied by haemorrhages from the stomach, intestines, and other organs, by derangements of the nervous functions, lumbar pains, dysuria, retention of urine, &c., which symptoms are followed by somno- lence and coma. The cause of the impaired secretion of urine has not yet been investigated with sufficient accuracy; Cormack, and other Scotch physicians, have detected urea in the serum of the cerebral ventricles and in the blood, in cases where death has been preceded by coma and con- vulsions, from whlc'h the existence might have been inferred, of more serioiis lesions of the kidneys than were found upon anatomical examina tion, so far as the published descriptions of the cases give us any infor- mation upon the point. This retention of urine and its consequences we shall presently find to be of much more frequent occurrence in yellow fever. Closely connected with the recurrent fever, both as regards its pro- gress being characterized by the occurrence of one or more paroxysms, and as to its anatomical lesions, is the fever observed by Griesinger, in Egypt, and first accurately described by him under the name of Bilious Typhoid, which, according to the experience of Lange at Konigsberg, may also be met with in the epidemic form in this country. In this fevei also, morbid conditions of the spleen and of the liver constitute the most important lesions found after death; the spleen, in a few days, becomes enlarged to five or six times its normal size, its tissue is interspersed with large infarctions, and the ^lalpighian corpuscles not unfrequently gradu- ally become filled with fibrinous exudation which is disintegrated into pus. The liver is at first turgid and congested; but subsequently it is found anrcmic, collapsed, and jaimdiced; the bile ducts are pervious, and in most cases filled with secretion. The kidneys become enlarged at an early period in a similar manner to the liver, and their glandular epithe- lium, like that of the liver, is filled with drops of oil. In addition to these morbid appearances, we sometimes meet with deposits in the mesenteric glands, ulcers of the larynx, such as we find in typhus, and likewise exu- dations, and collections of pus in various organs. Jaundice and bilious evacuations, both upwards and downwards, are common, but not con- stant, acompaniments of this form of fever; hamiatemesis occurs occasion- ally, and now and then tlie urine contains albumen or blood. According ' C'ORMACK, Natural HtHtor;/. Pathohr}y, d-c., of the Epidemic Fever. Edinburgh, 1843. DnhVuh Journal, 1849. Laxge. Beohachtungen am Krankenbette. Konigsberg, 1850. The author does not appear to be aware that Relapsing Fever constil*ited an important feature of many fever epidemics in Scotland and Ireland, before 1843. — Tkaxsl. ON DISEASES OF THE LIVER. 129 to Griesinger's experience, large doses of quinine exercise an unmistaka- bly favorably influence over the progress of bilious typhoid; but this does not appear to be always the case in the relapsing fevers of Scotland. c. Yellow Fever. The yellow fever bears a striking resemblance, in many of its symp- toms, to bilious typhoid. Here, also, the fever ceases after two or three days, but in most cases not to return. The severe symptoms, such as hemorrhages from the stomach and bowels, symptoms betokening a de- rangement of the nervous functions, lumbar pains, albuminuria, haema- turia, and suppression of urine, going along with the jaundice, which, in the forms of fever hitherto described, have been but rarely met with, are in yellow fever regularly present; important derangements of the nervous functions also frequently manifest themselves, — for the most part, under circumstances which afford some grounds for conjecturing that they have a uraemic origin. Roche found only traces of urea in the urine;* in the blood it was detected in larger quantity. Lallemant' describes a pene- trating urinous odor pervading the sweat and other secretions of patients laboring under yellow fever. The anatomical lesions are essentially different from those of remittent and recurrent fevers, inasmuch as the swelling of the spleen, which in these affections occupy a prominent place, are usually absent in yellow fever. The liver is at first congested and swollen, but afterwards it be- comes anaemic, yellow, of normal size, or somewhat smaller; the hepatic cells are found sometimes pale, in most cases devoid of nuclei, with scanty granular contents, and often filled with oil globules; the bile ducts are pervious; the gall-bladder is sometimes distended and at other times empty. The kidneys, in most cases, exhibit signs of acute exudation. There can be no doubt that in the diseases just enumerated bilious symptoms cannot be regarded as merely accidental complications, but that they are intimately related to the fundamental causes of the maladies in question. The infection of the blood, which we regard as the starting point of these morbid processes, first makes itself manifest by local lesions of the spleen and liver, and often of the kidneys also, which, again, in their turn, entail derangements of a special character. It is possible that these three organs mutually react upon each other, so that disease of one gives rise to disease of the others. The changes which are found in the liver afford no ground for explain- ing the jaundice by attributing it to catarrh of the bile ducts; the idea of a suppression of the secretion of bile is equally untenable; on the contrary, in intermittent and remittent, and also in recurrent fevers, the appear- ances presented by the intestinal contents and of the bile ducts is in favor of the idea of an increased secretion; or a true polychoiia.^ Whether these changes can be regarded as entirely the consequence of congestion of the organ, or whether the excessive formation of the products of meta- ' More accurate examinations of the urine in yellow fever would be of great in- terest, and so much the more as, in acute atrophy of the liver, very remarkable changes often take place in this secretion. (Vide Acholia.) \ Verbal communications. * See Annesley, oj). cit.^ Vol. I., p. 207 ; Vol. II., p. 429; also, Griesinger, op. cit. Vol. L— 9 130 A CLESnCAL TREATISE morphosis in the congested and swollen spleen contributes towards them, can only be determined with certainty when the relation of the materials found in the spleen to the formation of bile has been more clearly inves- tigated than has hitherto been possible. There are two principal causes which are to be regarded as accounting for the jaundice under the cir- cumstances before us; first, the increased secretion of bile overloading the bile ducts, which are insufficient for its removal, and so favoring its re- absorption into the blood; and secondly, the same conditions which give rise to jaundice in typhus, pysemia, and the allied morbid processes, such as blood infection, diminished secretion of the kidneys, &c. The anaemia and the shrinking of the liver, as also the abatement of its secretion, might be accounted for by the consumption of the blood by the splenic tumor, and partly also, by the haemorrhage from the stomach and bowels. I cannot regard these conditions as proving the existence of an acute atrophy, in the strict meaning of that term, such as Griesinger is inclined to think may exist, because the hepatic cells remain unaffected. ^Matters are somewhat different in yellow fever; in this affection, the morbid alteration of the spleen is usually absent; in general, no certain proofs exist of an excessive secretion of bile, although, on the other hand, the bilious coloring of the evacuations, and the distention of the gall- bladder with dark bile, are opposed to the idea of a suppression of this secretion, which is occasionally resorted to for explaining the existence of jaundice. The anatomical characters of the liver also are not in harmony with such a view; alterations of its intimate structure have long been souglit for in vain. The congestion which is present during the first pe- riod of the disease, gives way in its subsequent progress to a state of antemic collapse, with which is associated an infiltration of bilious matter, but the organ by no means presents the characters of acute atrophy; the hepatic cells, according to Blaclie, remain unaffected, although they be- come paler, and some of them contain fat. Excepting the fundamental changes in the composition of the fluids, so far as our researches as yet extend, the abnormal distribution of the blood, arising from the relative pressure of the blood in the portal vein being diminished by the profuse ha?morrhages from the stomach, wliich tends to propel the bilious contents of the hepatic cells into the vascular system, alone remains to account for production of the jaundice. It still remains for us to allude to the causes of the nervous symptoms, the delirium, the somnolence, and the coma, which are frequently ob- served in fevers complicated with jaundice.^ These symptoms have at all times been accounted for by the absorption of bile into the blood; and of late tlie forms of jaundice associated with t^^phoid symptoms have been united into one group under the designation oi Icterus gravis or ti/phoides. "NMiothor this view is correct or incorrect, will appear by a consideration of what lias been denominated cholremic intoxication. According to a tradition handed down from the most ancient humoral patliology, the bile, when it accumulates in the blood or undergoes certain changes, gives rise to nervous derangements of various characters, head- ache, delirium, convulsions, &c.' With a few interruptions, this view con- tinued generally prevalent, even after the authority of Galen had ceased to exercise any influence. The doubts expressed by Paracelsus and Van ' As regards the causes of these haemorrhages, I would refer to the next chapter. - " Bills ut |ihirinuim liominum insanise causa," Hippocr., edid. Kiihn, III.,j799 "Bilis ad caput recurreus delirii causa,"' Galen, Ed. Kuhn, XV., 741, 598. ON DISEASES OF THE LIVEE. 13i Helmont in their day met with little sympathy, for immediately after Syl- vius wrote concerning the narcotic properties of the bile, and of its capa- bility to excite comatose fever. Boerhaave, and Van Swieten ' appealee* to the testimony of the ancients in support of the dangerous effects ol this secretion, and Morgagni,* in his description of a case of jaundice which terminated fatally, calls the bile a " materies acrior cerebrum max- ime afficiens." In a similar manner, Stoll and Sarcone attributed the cause of convulsions and other dangerous symptoms to the hepatic secre- tion and its derivatives. In more recent times, pains have been taken to distinguish by careful examinations the various qualities of the bile, which the majority of the medical profession have during centuries believed in; but the results arrived at have been so unimportant that for the future we must not expect that the subject will receive much elucidation from this line of investigation.* • The attempts to ascertain more accurately the effects of the bile upon the nervous system by injecting this fluid into the blood, have been fol- lowed by such diverse results, that we are unable to draw any certain con- clusions from them. It is true, that Deidier * found that dogs speedily died after the bile of persons laboring under the plague had been injected or brought in contact with recent wounds; the animals also died into which Magendie ^ injected bile; but Goupil made experiments with an op- posite result, and Bouisson * found that death only followed when the fluid had not previously been freed from its coarser ingredients, and when, con- sequently, there was nothing to prevent the capillaries of the lungs becom- ing plugged up. More recently, these experiments have been oftentimes repeated by Th. von Dusch,^ but the results have been always uncertain; as a general rule, rabbits died of tetanic cramps, whereas dogs onl}' suf- fered from transient indisposition and vomiting. My own experience, which is founded upon an extensive series of injections, is in favor of the complete innocuousness of an accumulation in the blood of the biliary acids and their derivatives. AVhen bile which had been purified with the necessary amount of caution, and freed from its mucus and epithelium, or a solution of the glyco-cholate of soda, was introduced into the veins, no remarkable derangement of the nervous functions, or indeed of any func- tion whatever, took place. The only circumstances to be observed were, tliat the animals immediately after the injection licked with their tongues, proving the existence of a bitter taste proceeding from the blood, and that they voided urine, which deposited a flocculent precipitate of bile-pigment, and contained the dissolved red coloring-matter of the blood, and leucine." ' Van Swieten, Comment., T. I., p. 141 ; T. II., p. 271 ; T. III., p. 499. ^ MoKGAGNi, De sedibus et causis morb., Episb. 37. ^ I have examined the bile in a large number of dead bodies, and have caused it to be examined in a still larger number by Dr. Valentin. In a few cases we found albu- men, or .sugar, and, in typhoid diseases, leucine ; but, as a general rule, we could de- tect nothing abnormal, with the exception of varieties, in its degree of concentration, and differences in the coloring-matter, which at one time was crystalline, and at an- other time amorphous. * De bile peste emortuorum experimenta. Halleri Bibl. anat. 5 Precis de physiol., T. II., p. 260. « De la bile, 1«43, p. 60. " Untersuchungen und Experimente, als Beitrag zur Pathol, des Icterus, &c. Leip- zig, 1854. ^ Altogether, the number of injection experiments amounted to between 50 and 60, the greater number of which were undertaken, less for the object of observing the in- fluence of the bile upon the nervous functions than in order to trace farther the trans- 132 A CLINICAL TREATISE Hence we cannot consider the accumulation of bile in the blood as the cause of typhoid symptoms, and we are under the necessity of calling in question the existence of a cholaemic intoxication. In the fevers under consideration, this is the less likely to be the cause, as besides those forms which are accompanied with bilious symptoms, we meet with similar fevers, characterized by the same typhoid phenomena, in which jaundice is absent, and in which the bile cannot therefore be regard- ed as the explanatory cause of the phenomena in question. Hence we are obliged to attribute these phenomena to those obscure alterations in the composition of the blood, to which we ascribe the origin of malignant in- termittents, typhous fevers, &c. Where, as in yellow fever, and occasion- all}^ also in the other forms, there is persistent suppression of urine, or where, as in bilious typhoid, there is purulent infection, the explana- tion of the somnolence and coma is not difficult. The forms of fever, which we have been discussing, are for the most part peculiar to warm climates; in temperate climates, if we except the Scotch and Irish epidemics of relapsing fever, and the bilious typhoid of Kunigsberg, they are rarely met with. d. EPIDEMIC JAUNDICE. The epidemic forms of jaundice which have been observed in Germany and France differ from the above fevers in many respects. Among the best known are the following: — 1. The epidemic which prevailed in Essen ' in the year 1772, and which was described by Briinning." It attacked principally children, and assumed an intermittent type; various spasmodic affections and sometimes also delirium showed themselves in its course. A large number of chil- dren perished from it. 2. The epidemic in Liidenscheid described by Kerksig,^ ran a very mild course: less than seventy patients died of it. The jaundice usually appeared without any fever, after the precursory symptoms of gastrio catarrh had lasted from eight to fourteen days; the stools were pale. Children remained completely exempt; of five pregnant women who took the disease, three aborted, two of whom were attacked on the third day after delivery with fever, which was accompanied by delirium and coma, and terminated fatally. 3. In the epidemic of Greifswald in the years 1807 and 1808, observed by Mende,^ a fourth part of all the patients had jaundice. The jaundice was in some cases unaccompanied by fever, and in other cases it was asso- ciated with fever, which was of a remittent or an intermittent character. In the latter case, it was the tertian type which predominated. During the intermission, the yellow color not unfrequently receded, to reappear during the paroxysm; and in other cases it remained throughout the dis- ease. One patient died under severe nervous symptoms. formation of the colorless bile-acids into bile-pigraent. It is evident that the solution ought to be filtered before being injected ; moreover, it ought not to be concentrated, because it then assumes a slimy consistence, and easily produces obstructions to the circulation. These circumstances may, perhaps, in part explain the anomalous results obtained by Von Dusch. ' Essen is a market-town in Westphalia.— Traxsl. ' De ictero spasmodico epideraico Essendise. " Iluf eland's Journ. Bd. VII. ■• Hufelaud's Jouru. Bd. XXXI. ON DISEASES OF THE LIVER. 133 4. The epidemic in Chasselay, which was observed by Chardon,^ was very mild. The jaundice commenced with gastric catarrh, and was unac- companied by fever; the stools were in all cases pale. Not a single case proved fatal. 5. During the epidemic which in the year 1826 prevailed along the Coast of the North-West of Germany and of Holland,* bilious fevers fre- quently made their appearance along with intermittents and remittents; usually they presented a double tertian or a remittent type. Even at the present day, similar forms of fevers are occasionally met with in these marshy districts, where I have repeatedly had an opportunity of treating them. The anatomical cause of the jaundice in the epidemics just mentioned is very imperfectly known; and hence the determination of the mode of production of this symptom must in many respects remain uncertain. The predominance of the intermittent type of fever in these cases, and the often observed increase of the jaundice during the paroxysms, are circum- stances deserving of notice. In the Coast epidemic of 1826, the most constant lesions were remarkable enlargement and softening of the spleen, together with congestion of the liver, — changes the same as are found in tropical fevers, but in a milder form. After the inundation in Silesia in the year 1854, I had abundant opportunities of collecting observations on malignant intermittent and remittent fevers, some of which were compli- cated with bilious symptoms. Here the post-mortem examination, in ad- dition to congestion of the spleen and liver, disclosed abundant accumu- lations of black pigment in the spleen and in the blood, as also in the other organs, especially the liver, which in most cases was softened, and had the greater number of its capillary vessels filled with this pigment. De- lirium, convulsions, and coma were frequently observed during life, but the cases which were complicated with bilious symptoms were not more remarkable in this respect than those cases in which this complication was absent.* The epidemics in Liidenscheid and Chasselay which ran their course without fever, commenced with catarrh of the stomach and bowels, and were accompanied by light-colored stools. They were to all appearances examples of simple catarrhal jaundice, and only differed in their extensive prevalence. Appendix to Chapter on Jaundice. 1. Jaundice of newly -horn Children. — Icterus neonatorum. In a tolerably large number of newly-born children the skin and con- junctiva are tinged yellow, and the urine contains the brown coloring- matter of bile, which here, as elsewhere, indicates the existence of jaun- dice, and distinguishes this from all other yellow discolorations. As a general rule, the origin of this appearance is connected with changes which the function and the circulation of the liver undergo during birth. If we except the less frequent causes which may give rise to jaundice at this, as at other periods of life, such as catarrh of the bile ducts, occlu- sions of the ducts by thickened bile or by concretions, — instances of which ' Bulletin de TAcad. de Med., 1842, T. I., p. 112. ' PoPKEN, Historia epidem. malignaa. Jeverae observat., 1826. ^ See Chapter VIII., on " The Pigment Liver." 134 A CLnncAL treatise have been recorded by Lieutaud, Portal, Cruveilhier, and Bouisson,' and farther, congenital obliteration of the bile ducts,^ thickening of Glisson'a capsule, and congenital cirrhosis of the liver, ^ — we find that icterus neo- natorum is at one time the consequence of phlebitis umhilicalis, but at other times is merely one of the results of the revolutions which take place in the infantile organism during birth: — a twofold origin, which the older authors had already intimated in distinguishing the more severe from the milder forms of this affection. The jaundice which is dependent upon phlebitis umbilicalis, is produced by the purulent infection, to which this phlebitis may give rise; it exhibits all the peculiarities of pyaemic jaun- dice, and terminates, as this almost invariably does, in death. The yellow tingeing is here only a subordinate phenomenon in the complex train of symptoms of phlebitis. The more common form of icterus neonatorum presents very different characters; it appears as a very mild affection, which in most cases termi- nates favorably, without any treatment; but which is still a subject of con- troversy in reference to the conditions under which it makes its appear- ance. It has been attributed to an accumulation of meconium (e/] -P. Frank), to catarrh of the duodenum and of the bile ducts, to spasm of the ducts, polycholia, &c. ; but in most of the cases, the supposition of the existence of such exciting causes is justified as little by the symptoms during life, as by the 2)ost-mortem appearances. The mode of production of icterus neonatorum in ordinary cases, must be sought for in the diminislied tension of the capillaries in the hepatic tissue, which takes place upon the stoppage of the influx of blood from the umbilical vein, and which gives rise to an increased transfusion of bile into the blood. In strong, fully-developed infants, the equilibrium of pressure is soon restored; but in infants prematurely born, where the res- piration is a long time in becoming established, and where the foetal ves- sels remain long open, a more or less intense degree of jaundice is apt to make its appearance. Hence, as Bednar '' and West ' have rightly observed, it is infants prematurely born who are peculiarly liable to jaun- dice. Icterus neonatorum usually appears soon after birtli, sometimes even within a few hours, or the color becomes most distinct about the third day, and then as a general rule, lasts one or two weeks. The skin and the eyes present a more or less dark jaundice hue; the urine also is of a deep- er yellow than usual, but does not exhibit the dark-brown color of other forms of jaundice (which may be explained by its greater dilution), and often it does not even present distinctly the reaction of bile-pigment. At first, there is constipation, and the stools are pale, but afterwards they are of a normal color; and now and then they are seen more intensely colored than under ordinary circumstances. The general health remains unaffect- ' De la bile. p. 187. ^ DoNOP, Be ictero specintim neon atom m Dm. Berol.. 1828. Campbell, North- ern Jonvmil of Medicine, Aug-ust, 1844. It is worthy of notice that infants succumb nuich earlier than adults to the effects of an interruption of the flow of bile into the iuLestiue, and in most cases, indeed, haemorrhages take place from the umbilical ves- sels. •' F. Wkker. Ilcitrage zur path. Annt der Neugcborenen. III., Lief., S. 47. ^ Kraiikli. dor Neujjeborenen, IV., S. 194. 5 Pathulog-ie der Kinderkraukh. Translated from English by Wagner, S_. 396. West lays great stress upon the obstructed respiration, and the impeded functions of the skin, a.s causes of icterus neonatonon. ON DISEASES OP THE LIVEE. 135 ed; and in most cases there is no alteration in the frequency of the pulse. Certain external causes of the affection are not usually referred to; but bad nursing, and the exposure to a cold or polluted atmosphere, exer cise a powerful influence, as is shown by the statistics of Foundling Hos pitals. In this simple form of icterus neonatorum, scarcely any treatment is required. Mild, laxative medicines, such as syrup of rhubarb, and, if ne- cessary, a small dose of calomel with magnesia, and afterwards a few warm baths, with simple diaphoretics, include all that is usually necessary un- der such circumstances. 2. The Jaundice of Pregnant Females — Icterus Gravidarum. Pregnancy may give rise to two forms of jaundice, which in their symptoms and results present very different characters: one of these is of very little importance, but the other is associated with serious lesion of the hepatic tissue, and almost invariably terminates in death. The first of these forms makes its appearance in the later months of pregnancy, and is produced by the distended uterus, or by the accumula- tion of fascal matter in the colon, exercising a degree of compression upon the bile ducts, which impedes the free passage of the bile.' Sometimes the affection is developed in the earlier periods of pregnancy, and de- pends upon catarrh of the bile ducts, or upon mental emotions. This simple form of jaundice is attended by no consequences; it disappears upon delivery, if it has not yielded spontaneously at an earlier period to laxative medicines.' The second form is characterized by serious derangements of the ner- vous system, and, so far as cases of it have as yet been examined, depends upon acute atrophy of the liver, resulting from inflammation of the paren- clij^ma of the organ : as a general rule the kidneys are at the same time diseased. (See Chap. V. on Acholia.) ' This view was long ago expressed by Van Swieten ( Comment, ad Boerh. apJior. , Tom. III., p. 95). ViRCiiow )Oesammelte Abha?idl., S. 757) observed jaundice in one pregnant female, in whom a tight-lace lobe of the liver, together with the gall-bladder, was turned up in such a way that a stoppage of bile necessarily resulted from the ten- sion of the bile ducts. ' J. P. Frank, however, met with a csise in which a fatal rupture of the gall* bladder took place during delivery. CHAPTER y. SUPPRESSION OF THE FUNCTIONS OP THE LIVEE.— ACHOLIA, AND ITS CONSEQUENCES. In the last chapter, we became acquainted with a series of morbid pro- cesses, in which jaundice was in some instances accompanied by serious derangements of the nervous functions. In these cases the jaundice was associated with certain forms of fever, proceeding from an infection of the blood, and appearing as epidemics, and rarely in the sporadic form; usu- ally, no important morbid alterations of the liver were present; the cells of the gland remained unaffected, their secreting activity continued unim- paired, and frequently was even increased; the typhoid symptoms were independent either of the liver or of its secretion. From this form of jaundice Ave must distinguish a second, which always comes on sporadically, and depends upon a suspension of the secretion of bile, and as a general rule is produced by acute atrophy of the liver, and in some instances by other structural diseases, such as cirrhosis, fatty degen- eration, &c. It is much more dangerous than the former variety, and al- most invariably terminates fatally. In their symptomatology, both have many features in common; and although extreme cases of each may pre- sent very different characters, both as regards their progress and anatomi- cal lesions, still, on the other hand, there are cases where it is very dif- ficult to draw a distinction, not only during life, but even on the 2^ost- mortem table. The principal cause of this difficulty consists in the fact, that in the first form the enlargement and the excessive secretion of the liver, are followed by an opposite condition of collapse and suppression of secretion, which in many respects resembles atrophy; a second cause is the circumstance that the anatomical diagnosis of simple typhus with jaundice is often difficult, inasmuch as the nervous derangements belonging to ty- phus may be ascribed to the jaundice; and a third arises from the circum- stance that the suspension of the functions of the liver being far from suf- ficiently known, it is only provisionally inferred, that structural lesions of tlie liver exist. AVe have already seen, that enlargement and albuminous infiltration of the liver and kidneys are not unf requently present in infectious diseases; tliis constitutes the commencement, or the first stage of diffuse infiammation, from which proceed destruction of the hepatic cells, and atrophy of the gland. Typhus and the allied morbid processes may in this way become the remote causes of acholia, although this condition has usu- ally a different origin. In order to form a clear idea of acholia, we are obliged to be guided by ol)Scrvations of cases, in which there has been a complete stoppage of the function.-: of the liven- owing to an unmistakable general change in the structure of tliis organ. The results obtained in this manner may serve as ON DISEASES OF THE LIVEE. 137 a clue for explaining the more obscure forms.' For this purpose I have selected acute atrophy of the liver as a starting-point, and in my analysis of facts I have only made use of those observations which were undoubt- edly examples of this affection. A. THE ACUTE OB YELLOW^ ATEOPHT OF THE LIVER. Atrophia hepatis flava sive acuta. — Hepatitis diffusa. History and Literature. The first authentic communications on acute atrophy of the liver are found in Morgagni's works.* It is true, that in more ancient literature, descriptions of diseases occur which correspond to this affection in their symptoms, but the anatomical proof was wanting or insufficient. Jacob Vercelloni ' gave an account of the disease from which his brother suf- fered; being hardly pressed by his creditors one night, he became sudden- ly jaundiced from fright, and soon fell into a restless delirium, with a re- markably irregular pulse and panting respiration, and died on the third day. Francis Rebeus * mentions an analogous case of jaundice where death occurred on the fifth day amid severe cerebral symptoms. Of a similar nature is the observation recorded by Baillou * of a boy aged 14, who, on the fifteenth day of an apparently slight attack of jaundice, with white evacuations, suddenly fell into delirium and convulsions, gave utterance to loud inarticulate sounds and died. Upon post-mortenx examination, the brain was found healthy, " pulmo vitium insigne contraxerat, vitiosius he- par et velut vKepij/kuyp.^^ Bonet * gave the description recorded by Guarinonius, of the history of the disease of Cardinal Sforza, who died on the sixteenth day of an attack of jaundice, after having suffered, for the last three days of his life, from delirium and convulsions. The liver was yellow; the blood, dark and fluid. In Morgagni's works we find some of these cases re- peated, and, in addition, two more instances from Valsalva's practice, in both of which the jaundice was the result of violent mental emotions. Both patients were young; and died, one, two days, and the other twenty- four hours, after the commencement of the jaundice. " Jecur inventum est flaccidum et ad subpallidum vergens." All these observations remained for a long period dispersed through the writings of different authors, attracted but little notice, and were not referred to in any systematic work. The larger proportion of the materi- als in our possession have only been collected in recent times, especially ^ Two mistakes have, in my opinion, been committed in treating of this difficult sub- ject ; one, that all cases of severe jaundice have been referred to acute atrophy of the liver (the old school, and especially Haraczek) ; and the other, that sufficient accuracy has not been observed in the selection of cases of typhoid jaundice, and the two groups distinguished by me have been confounded together, or at all events, doubt- ful cases have been made use of in the accounts of the disease ( Ozaruim and Lebert). * De sedibus et causis morborum, Epist. X., 7, et Epist. XXXVII., 2, 4. ^ Jac. Vercelloni, de bile aucta et imminuta, Epist. ad Bianchi, p. 194. * Fr. Rube us, de ictero leth. noct. exercit., 1660, p. 195, after Ozanam. ^ Ballonii Ephemerid. lib. II., p. 188. BaUlou cites another similar case from Ga- len ; who thus explains the cause of death : — " Non vi phrenitidis sed ob dominatum humorum virulentorum, qui sua maliguitate virus adaequant." * BoNETi, Sepulchret., p. 1007. 138 A CLINICAL TEEATISE since Rokitansky has accurately described the anatomical characters of acute yellow atrophy of the liver, and since Horaczek, and Budd in Eng- land, have given a general description of malignant jaundice. The bulk of the observations, however, which have been as yet accumulated, con- tain very heterogeneous materials resembling one another only in their external characters, so that in order to make use of them, it appears in- dispensable to have recourse to a careful sifting, in performing which the anatomical lesions must be our sole guide. Of the modern sources of information upon the subject the most im portant are the following: — Alison. Edinburgh Med. and Surg. Journal. 1835. R. Bright. Guy's Hosp. Reports. Vol. L Maktinet. Biblioth. Medic. Vol. LXVL Aldis. London Med. Gazette. XIIL Rokitansky. Path. Anat. Bd. III. BuDu. Diseases of the Liver. P. 207. Horaczek. Die gallige Dyscrasie, &c. Wien, 1843. WissiiAUPT. Prager Vierteljahrsschrift. 19, 38. OzAXAM. De la forme grave de I'ictere essentiel. Paris, 1849. Kiwiscil. Geburtskundc. IL, S. 51. RiJHLK. Giinsberg's Zeitschr. IV., 1 Hft. Frey. Archiv f . phys. Heilk. IV., S. 74. Gluge. Atlas der path. Anat. Spath. Wiener med. Wochenschr. 1854. Pr,EiscnL. Ditto. 1855, No 1. Klinik der Geburtshiilfe von OniARl, Braun and Spath. 345. BtJiiL. Zeitschr. f. ration. Med. 1854. Lebi:i:t. Ueber Icterus typhoides. Virchow's Archives. 1854. Si'ENGLBR. Ditto. Ditto. 1855. We UTii ['TIMBER. Fragraente zur Lehre vom Icterus. Von Duscif. Untersuch. u. Experimente zur Pathogenese des Icterus. 1854. Aertzlicher. Bericht des allgem. Krankenhauses in Wien, vom Jahre. 1855. S. 53. Guckelberger. Wiirtemb. Correspoudenzblatt. 20. 1856. II. Symptomatology of Acute Atrophy of the Liver. The symptoms which accompany acute wasting of the liver are some- times preceded by a preliminary stage; but at other times manifest them- selves directly. The precursory symptoms present nothing characteristic; usually they resemble the symptoms of an acute gastro-enteric catarrh; the patients get out of sorts, complain of dulness and headache; their tongues are coated, and the bowels are irregular, sometimes relaxed, and at other times confined; the abdomen is tender; the pulse is increased in frequency. Sooner or later, sometimes not until after the lapse of several weeks, a slight jaundiced tint of the skin supervenes upon these derangements. The jaundice may exist in the simple form from eight to fourteen days, or even longer, before the local changes in the liver and spleen, the ha?morrhages and the serious derangements of the nervous functions, which characterize the affection, become apparent. These symptoms, however, make their appearance about the same time as the jaundice, quite as frequently as they follow in its wake. The disease runs a more or less violent course; in severe cases the scene terminates at the end of twelve or twenty-four hours, in other cases, after two or five days; it is scarcely ever prolonged to a week. The symptoms usually commence with vomiting, by means of which there is thrown up fir-st the contents of the stomach, then gray mucus, and lastly, blood, in the form of dirty-brown, or ultimately, black coffee- ON DISEASES OF THE LIVER. "139 ground masses. At the same time, severe pains in the head come on, which, as a general rule, soon pass into delirium. In most cases, this de- lirium is noisy; the patients scream out and beat themselves, try to leave their beds, and are with difficulty restrained. In other instances, they are quieter, and can be roused for a short time by loud shouting. The delirium is usually succeeded by convulsions, which extend over most ol the voluntary muscles, or are confined to certain localities, such as the muscles of the face and neck; now and then also they appear in the forir of trismus, and in certain cases one half of the body is implicated to t greater extent than the other. Along with these spasms (which, how- ever, are not invariably present), we observe, as a general rule, a tremu- lousness of the muscles of the extremities and trunk. The patient after a time becomes by degrees more and more tranquil; the state of excitement passes into stupor, and finally, into deep coma; the pupils become large, react slowly with light, and the respiration becomes sighing, intermittent, and stertorous. The pulse, which at first was slow, and continues so as long as the jaundice remains simple, at the outbreak of the nervous symptoms in- creases in frequency, and gradually rises to 110 or 120 or thereabouts; at the same time, it presents remarkable variations as regards its frequency and volume : sometimes when the patients are roused, the pulse rises from 70 or 80 to 120 or 130, soon again to sink to its normal frequency or be- low it. These oscillations in the frequency of the pulse, which may also be observed in respect to its size and hardness, cease when the disease draws towards a close; the pulse then always increases in frequency and becomes smaller until it can no longer be felt. The tongue and teeth are covered at an early period with a fuliginous crust; the abdomen is in most cases, but by no means always, tender upon pressure, especially in the hypochondriac regions, and particularly the right one; even during the coma, when the hand is applied here, it pro- duces distortions of the features and loud complaints. The extent of the hepatic dulness diminishes more and more as the disease advances, and not unfrequently the dull space disappears completely, without there be- ing any tympanitic distention of the bowels to account for it; at the same time the spleen is increased in volume. The bowels are almost always confined, and the stools are firm, dry, clay-like, deficient in bile, and, at a later period, not unfrequently dark-colored, and tarry from the presence of blood. In the meantime the color of the skin increases in intensity, and numerous extravasations of blood take place into its tissue in the form of petechife and more extensive ecchymoses; along with these there are hasmorrhages from the nose, the vagina, the stomach and bowels, and the bronchi. The urine is more or less saturated with a brown coloring-matter, pre- sents the reaction of bile-pigment, and deposits a light precipitate, in which with the microscope there may be detected besides amorphous mucus, the epithelium of the urinary passages and sometimes likewise of the kidneys, colored yellow, and also needle-shaped crystals covered with coloring-matter, either isolated or adhering in crystalline masses. Some- times the urine contains albumen. The various derangements just described usually terminate after a few days in death, which usually occurs amidst increasing coma, and other symptoms of cerebral paralysis. It very seldom happens (and the ob- servations in proof of such an event are still of a doubtful character), 140 A CLINICAL TREATISE that, after very free evacuation of the bowels, consciousness returns, the jaundice diminishes, and recovery takes place. in. Illustrative Cases, Obsebvation No. XIV. Repeated attacks of I/amhago in the seventh month of Pregnancy. — Gastric Catarrh. — Icterus. — Delirium. — Convulsions. — Coma. — Death under symptoms of Blood-poisoning. Acute Atrophy of the Liver. — Complete disintegration of the hepatic cells. — Crystalline deposits in the tissue of the Liver, and in the blood of the hepatic veins. — Enlargement of the Spleen. — Abortion. The wife of Dr. Sch., chief Physician at Kiel, 33 years of age, of shprt stature, delicate, and sensitive, had suffered much distress of mind during the three years' war; she often sat for an entire day in tears; she was in easy circumstances, and the mother of three children. Since her last con- finement, there had been a hardness in her left mamma, which had origi- nated under symptoms of inflammation, but subsequently had assumed the characters of scirrhus. The post-mortem examination showed in the sequel the carcinomatous nature of this hardness. In December, 1850, Mrs. Sch. was in the fifth month of pregnancy, and had complained of nothing save the usual symptoms incident to that condition. In conse- quence of an unforeseen excitement, the patient was seized on rising from stool with severe pains in the muscles of the lumbar region of the spine, and was obliged to keep her bed. Although this local suffering was unimportant, still it was the commencement of a series of complaints which gradually exhausted this delicate lady, and ultimately led to a dis- ease which terminated fatally. Fourteen days elapsed before the pains, which at the first were accompanied by smart fever, disappeared under local abstraction of blood, and rest in bed, &c. The patient remained for some days well, when on rising from stool, the pain suddenly returned at the same place, and with the same degree of violence. This time the fever was more acute, and the skin very active; tlie tongue was for a long time thickly coated, and there were at the same time nausea and complete anorexia. Fourteen days passed before the patient was freed from her sufferings. A second relapse, which made its appearance in the same Avay as the first, confined the patient to bed for a third time. Meanwhile she became emaciated; a bed-sore formed over the sacrum, which at first took A favorable course, but was very slow in healing. The patient had begun to recover, when suddenly an important change in her condition took place. In the first place, pains were complained of in the epigastric region, and in both hypochondria, which were increased by slight pressure; the hepatic region was particularly tender. Percussion indicated a consid- erable diminution in the hepatic dulness, which was the more remarkable, as there was no accumulation of gas in the intestinal canal to account for it. By degrees, the dulness in the right hypochondrium completely dis- appeared, whilst an examination of tlie spleen indicated a rapid increase in the \()iunie of this organ. The tong-ue again became coated; the ap- ]-ctite diminished; and there was repeated vomiting of a dirty-gray mu- ON DISEASES OF THE LIVER. 141 cous fluid. The bowels were torpid, and had to be opened by means of senna. The stools were at first of a dark color, and subsequently they exhibited a gray clay-like appearance. The pulse, which a short time before had been 80 to 90, sank to 64, then rose again to from 75 to 80, and towards the termination of the disease reached 110 to 130. Almost simultaneously with the pain in the hepatic region, the conjunc- tiva was observed to present a yellowish color, which soon became more distinct, and extended over the skin, without, however, attaining a high degree of intensity. The cerebral functions, which, with the exception of a gloomy despondent disposition, had hitherto remained normal, under- went a sudden change, twelve hours after the outbreak of the jaundice; the patient complained of violent pains in the head, became restless, made attempts to leave her bed, and wandered in her mind. This excitement soon passed off, to make way for a rapidly-increasing somnolence. The patient lay in a stupified state with enlarged pupils, and from time to time convulsive movements occurred of the muscles of the face, neck, and arms; she drew short sighing inspirations, each of which was succeeded by a quick expiration and a pause. The pulse was 130; the urine and stools were passed involuntarily. The skin was covered with clammy sweat. Death took place four days after the appearance of the jaundice. The treatment consisted in the administration of muriatic acid, at first by itself, but sub- sequently in combination with ether, and latterly with musk: purgatives, senna, and afterwards colocynth, were given along with these remedies, in order to overcome the obstinate constipation. Post-mortem examination, 30 hours after death. The body was emaciated, and of a moderately dark jaundiced hue. A foetus, enveloped in its membranes, projected -from the genital organs. The bronchial tubes and lungs were anaemic, but otherwise normal. The heart was flabby and shrivelled (icelk) ; the right ventricle contained a loose reddish-brown coagulum; and the left, a little thin blood. The spleen was remarkably enlarged; its parenchyma was of a reddish-brown color, and of normal consistence. The mucous membrane of the stomach was pale, and over the cul-de-sac and posterior wall was softened. The lining membrane of the large and small intestine was ansemic, without any marked development of its glandular system; here and there might be seen sharply-defined patches of the mucous membrane presenting a reddish- brown color, from passive congestion; the caecum and colon presented grayish faecal matter. In the sac of the peritoneum a pound of reddish-brown fluid was found, which exhibited the reaction of bile-pigment. The peritoneum itself was not injected. The kidneys were flabby and tinged yellow, and a portion of their secreting cells were in a state of fatty degeneration. The urine contained in the bladder was deeply colored by bile; but contained not a trace of the biliary acids.' The uterus, the membranes of the ovum, the placenta, and foetus exhibited nothing unusual. The last appeared free from any jaundiced tint, and presented by its breech. After its removal, a pound and a half of dark, completely coagulated blood escaped from the uterus. ' The urine was unfortunately not tested to ascertain the amount of urea, or the presence of the other substances which since then I have found in such cases. 142 A CLINICAL TREATISE The liver was very considerably atrophied, flabby, and shrivelled (welk); it was atrophied especially as regards its thickness, which, close to the suspensory ligament, amounted to half an inch, and at the thickest part of the right lobe to scarcely one inch. The serous covering was puckered; the cut surface of the organ was smooth, shining, and of an ochre-yellow color; there was no visible subdivision into acini. The gall-bladder contained a small quantity of grumous bile, mingled with a few small black concretions, of a neutral reaction, and exhibiting the or- dinary reaction of bile-pigment and glycocholic acid. The aperture of the hepatic artery appeared to present its usual calibre, and there was nothing abnormal about its walls. The portal and hepatic veins were also of nor- mal calibre; the bile ducts were pervious, and their lining membrane was pale. No trace of the hepatic cells could be detected upon microscopic examination of the hepatic tissue. This consisted of fine molecules, part- ly yellow and partly pale; and here and there were seen large, dark-brown conglomerate masses, with irregular outlines. Some drops of oil, and rounded, sharply-defined formations, which resembled the nuclei of hepat- ic cells, were also perceived. Amidst this detritus of the secreting appar- atus of the liver, there were observed numerous needle-shaped crystals ad- hering together in bundles, or in radiating masses (tyrosine).' These crystals were found in much greater abundance in the blood of the hepatic veins, which contained a thin reddish fluid, in which, along with normal blood-corpuscles, there floated numberless crystals in bundles and radiating masses.^ They were entirely absent from the blood of the portal vein and hepatic artery. The liver was washed in cold water, to free it from its adherent blood; it was then cut in pieces, triturated, and boiled. The filtered fluid, upon standing, deposited numerous crystals, adhering partly in bundles, and partly in radiating masses (tyrosine). ^Vhen farther concentrated, a grayish-yellow film formed at the margins and over the surface of the fluid, and there separated, a large quantity of brown globular masses, made up of concentric layers (leucine). Owing to tlie smalbiess of the portion of the liver which had been subjected to the experiment, the quantity of crystals obtained was unfortunately too mi- nute to determine their nature with complete certainty. Obsketation No. XV. Si/ynptoms of Gastric Catarrh and Jaxmdice in the seventh month of Prprjnancy. — Delirium. — Convidsions and Coma. — Abortion. — Death on the severdh da)/ of the disease. — Acute Atrophy of the Liver. — Haem- orrhage from the Intestinal Caned, and from the 3Iucous Membrane of the JironcJii, tOc. — Ptcidiar composition of the Urine. P. Nitschke, aged 2-1, a carpenter's wife, was brought in a semi-con- scious state to the clinical department of All-Saints' Hospital, on January 21st, 18o8. The patient was a robust, v,'ell-nourished female, of a florid complexion; who, according to the statements of her relatives, had pre- viously enjoyed uninterrupted good health; she was in the seventh month of pregnancy. On the ITth, she had complained, as we were informed, of symptoms resembling those of acute catarrh of the stomach, loss of ap- • Frontispiece, Fig. 1. "^ Frontispiece, Fig. 2. ON DISEASES OF THE LIVER. 143 petite, along with constipation, headache, general malaise, and great de- jection of spirits, and, in short, derangements which, although not urgent, appeared sufficient to call for medical assistance. On the 20th, she came to Dr. Hasse as an out-patient, and he immediately recognizing the impor- tance of the case, directed her to be admitted into one of the medical wards. He then observed a slight yellow tinge of the face. During the ensuing night the patient, after repeated vomiting of a dirty-gray fluid, suddenly became delirious, shouted out disconnected words, and could with difficulty be kept in bed. This state of excitement still continued at the time of the patient's admission into the clinical ward; the pulse was 80; respirations 20; the temperature of the skin was not elevated; the pupils were of normal size, and acted somewhat slowly. The conjunctiva was of a pale-yellow tinge, as also the skin of the face and neck, whilst on the abdomen and lower extremities no jaundiced tinge could be recog- nized. The abdomen was soft, without any very great accumulation of gas; both hypochondria and epigastrium were tender upon pressure. On percussing the hepatic region, the dulness in the axillary line amounted to only 3 centimetres (1-^ inch); in other situations, there was a direct transition from the sound of the intestine to that of the lung. No dulness corresponding to the spleen could be made out. The thoracic or- gans remained intact. She was ordered muriatic acid. In the night be- tween the 21st and 22d, the restlessness increased; the patient kept con- stantly uttering loud unmeaning cries; and the eyes remained open, the pupils being normal. The pulse rose to 112, without any elevation of the temperature, and the respirations, which were stertorous, to 26. At eleven o'clock of the 22d, the patient was delivered of a dead seven months' foetus, which presented no trace of jaundice. This was followed by a profuse uter- ine haemorrhage. After the abortion the excitement abated; and the patient lay, sometimes, at least, in a quiet, unconscious condition; the pulse and respiration remained unchanged; the pupils continued to act distinctly, al- though slowly, upon exposure to the light. The jaundice had slightly in- creased since the day before; the hepatic dulness was nowhere more obvi- ous than formerly; and the spleen was equally undistinguishable by per- cussion.' The bowels had been confined for three days; the urine, which had to be drawn off by catheter, was acid, reddish-yellow, clear, and free from albumen; its specific gravity amounted to 1018.5. Upon the addi- tion of nitric acid, the color became darker, but did not exhibit the play of colors characteristic of bile-pigment. Upon standing, it deposited a slight sediment, which consisted of numerous needles, partly isolated and partly adhering in groups, along with the j-ellow-tinged epithelium of the blad- der and of the uriniferous tubes. Tincture of colocynth, and subsequent- ly jalap,' were administered along with the muriatic acid, to remove the constipation. During the night, between the 22d and 23d, the patient lay quiet, and in a state of deep coma: muscular tremors were observed in the neck and upper extremities. The haemorrhage from the vagina continued. On the morning of the 23d, the jaundice appeared increased; pulse ' I remarked in the Clinique, that this absence of splenic dulness could not be re- garded as incompatible with acute atrophy of the liver, although this affection is more frequently attended by an increase of the volume of the organ, because the spleen not unfrequently lies high up in the hollow of the diaphragm in such a manner, that al- though enlarged it is necessarily out of the reach of percussion, and, moreover, because old thickenings of the capsule may interfere with its enlargement. 144 A CLnacAL treatise 108; respirations 24, and stertorous; no elevation of temperature; skin dry. From time to time vomiting occurred; by which gray mucus, mingled with brownish-black flakes, were thrown up. The bowels remained con- fined, notwithstanding the colocynth. The urine was darker in color, acid, gave distinctly the reaction of bile-pigment, but not of the biliary acids; its specific gravity had risen to 1024. After standing in the cold air, a greenish-yellow, light sediment was deposited, consisting entirely of acic- ular crystals of tyrosine aggregated together in globular masses. When a drop of urine was evaporated upon the object-glass, it left behind a resid- uum, which, upon microscopic examination, was found to be almost ex- clusively composed of the most characteristic possible crystals of leucine and tyrosine, partially saturated with coloring-matter.* A portion of the urine, immediately after it was drawn off by catheter, was freed from its coloring and extractive matter, by treating it with an excess of the basic ace- tate of lead, the excess of lead was then removed, and what remained was condensed and set aside. In twenty-four hours there was obtained a quantity of tyrosine sufficient for several elementary analyses, in the form of brown and greenish-yellow globular crystallized masses; ' the identity of which was proved, first, by the crystalline form after re-crystallization,* then by Piria's test,* and, lastly, by Staedeler's process of elementary anal- ysis. The comatose condition of the patient remained unchanged: there was no enlargement of the pupils. In the afternoon, the pulse rose rapidly to 1.34; the skin became cov- ered with clammy-sweat; and death took place about 7 o'clock. During the last two days of life, first ether, and then tincture of musk were administered alono' with the mineral acid. Aut02)sy, 18 hours after death. The body was fat, and showed no signs of incipient decomposition. The skin on the head, neck, and chest was considerably jaundiced, as also the sclerotic; on the lower extremities the color was paler. ' See Frontispiece Fig. 5, which exhibits a drop of the urine thus evaporated. The leucine was deposited partly in globular masses, with concentrically thickened walls and fissured surfaces, and partly in finely -striated lamiuaj : along with it there were observed greenish-yellow crystals of tyrosine. - See Frontispiece, Fig. 6. ^ Frontispiece, Fig. 7. ■* In Piria's test, advantage is taken of the dark-violet color which is produced when tyrosine is treated with sulphuric acid and perchloride of iron. If a small quantity of tyrosine, or of a substance containing a minute trace of it {-^.-^ grain is sufficient), be placed in a watch-glass, moistened with one or two drops of sulphuric acid, diluted, after half an hour, with water, then heated and saturated with carbonate of lime, and if to the filtered fluid perchloride of iron (containing no free acid' be added, the pres- ence of tyrosine is indicated by the a]ipearance of a dark violet-blue color. Tyrosine and leucine may be obtained as artificial products of the decomposition of albumen and fibrine, when either of these substances, but particularly the latter, is heated with dry caustic pota,sh. or boiled with a strong solution of potash. They are also obtained in the decomposition of caseine and horn, by the action of alkalies and of acids, and Ity putrefaction. These substances are regarded as some of the intermediate products of the destruction of the animal tissues, between the sanguineous bodies at one extreme, and the still less complex excreted compounds, such as uric acid, hippuric acid, urea, kreritine, ttc, at the other. The composition of leucine is C12 NH13 Oi; that of tyrosine is d- XHu On. The crj'stalline forms presented by leucine and tyrosine are represented in the frontispiece. — Transl. ON DISEASES OF THE LIVER. 145 The skull-cap was normal; the dura mater, yellow; the pia mater, bloodless, as also the cerebral substance, which was of normal consist- ence; there was only a small quantity of clear serum at the base of the cranium. The mucous membrane of the larynx, trachea, and bronchi, was of a dark-red color from suffusion of blood; the lungs were normal, moderate- ly congested, and posteriorly and inferiorly slightly hypostatic. The heart was of normal size, and there were numerous ecchymoses beneath the epicardium; the ventricles contained a small quantity of tar-like blood along with a little colorless coagulum. The tongue, pharynx, and oesopha- gus were covered with a dirty grayish-brown coat; the stomach presented a pale mucous membrane without any visible ulceration; it contained a brownish - black coffee - ground - like substance, which was also found throughout the whole of the small intestine, as far as the ileo-ciecal valve. The large intestine contained scybala of fnecal matter, but faintly ting ed with bile. The mucous membrane of the bowel was everywhere pale and annemic. Numerous ecchymoses were found in the mesentery; the veins were not enlarged nor distended; and there was no enlargement of the mes- enteric glands. The spleen was fixed in the hollow of the diaphragm by old adhesions ; it was enlarged by about one-third, soft, and of a pale-red color. The liver lay collapsed against the posterior wall of the abdominal cav- ity; anteriorly it was completely covered by the folds of the small and large intestine, which were displaced upwards (Fig. 10, p. 36); it was dry and soft; its capsule was puckered and opaque, and its margin sharp. The dimensions of the organ were diminished in every direction, and par- ticularly in thickness. The gall-bladder contained a small quantity of gray mucus. The tissue of the liver felt flabby and dry; in the right lobe it was at some places congested; the ramifications of the portal vein sur- rounding the lobules were distended, whilst the centre of the lobules pre- sented a citron-yellow color; here and there were small ecchymoses. A grayish-yellow substance was observed in the spaces between the lobules, which were in this case still distinctly defined, owing to the surrounding network of vessels being injected. Near the sharp margin of the liver, the capillary injection disappeared, the rounded yellow islets appeared smaller, and consequently the surrounding gray substance seemed wider. In the left lobe, where the morbid process had advanced farthest, this in- ter-lobular substance was still more extensive; tho cut surfaces here ])re- sented an ochre-yellow color, interspersed through which were distiuct ramif^-ing streaks. The secreting cells were completely disintegrated, and in their place were found numerous drops of oil and brownish-yellow mol- ecules; it was only in the rounded border of the white lobe that a few isolated cells loaded with oil could bo detected. Upon exposure the out surface of the organ became covered with a grayish film, consisting of globules of leucine mingled here and there with crystalline masses of ty- rosine. In the blood of the portal and hepatic veins the blood -corpuscles were normal, and no crystalline deposits could be detected. The liver was injected with yellow size; this substance penetrated to the centre of the globules, and passed thence a short distance into the capillaries, and then became extravasated, without reaching the periph- eral vessels of the lobules. In fine sections of the tissue injected in this way, the enlarged central veins of the lobules could be seen surrounded by a yellow partially injected space, in which could be observed the crys- talline deposits just mentioned, and this again was surrounded' by a paler Vol. I.— 10 146 A CLINICAL TREATISE bluish-gray rim of densely aggregated oil globules. The weight of the liver amounted to 0.82 kilogrammes (1.807 lbs. avoird.), and the weight of the entire body to 56.2 kilogr. (123.898 lbs.), making the ratio of the former to the latter as 1 to 68.5. In healthy females of the same age and weight, the weight of the liver is about 2 kilogr. (4.409 lbs.), and the ratio is as 1 to 28. Thus the organ within six days had lost 1.18 kilogr. (2.601 lbs.) in weight. It was also considerably diminished in size; the left lobe measured 3 inches transversely, and o^ from before backwards; and the right lobe 5^ inches by 1^; the thickness was 1^ inch. The urine voided during life was now subjected to a closer examina- tion. It left behind 4.9 per cent, of solid residue, and 0.14 p. c. of ash. The residuum mainly consisted of leucine, tyrosine, and a viscid extrac- tive matter, along with traces of uric acid; urea was sought for in vain; and ammonia was present in such small quantity that the supposition of the urea having disappeared from decomposition could not be entertained. This idea was also opposed by the circumstance, that the urine examined immediately after it was voided was found to be acid. It was also re- markable, that phosphoric acid and lime were entirely absent from the ash. Upon evaporation, the urine deposited a considerable quantity of a greenish-yellow sediment, which was collected and treated with diluted ammonia. From this solution there separated long delicate acicular crys- tals, possessing all the characters of tyrosine; on analysis, they yielded 8.03 per cent, of nitrogenous contents, which coincided with the formula of tyrosine. On evaporation of the ammonia, there remained behind a substance similar to tyrosine, and crystallizing in like manner, but which differed in its being more soluble, and in containing a larger proportion of nitrogenous matter. (8.83 per cent.) The residuum of the urine was repeatedly extracted with absolute alco- hol, so as to obtain any urea present. Tliis solution upon the addition of half its volume of ether, deposited an amorphous substance, from which crystals of leucine gradually separated. Tlie ether was evaporated from the filtrate, which was then treated with an alcoholic solution of oxalate of lime. A crystalline precipitate was formed, which was dissolved in water and decomposed by carbonate of lime. The filtered fluid when evaporated left behind a very scanty residuum, in vvliich, on testing with nitric acid, no trace of urea could be detected. The salt thrown down by oxalic acid consisted of oxalate of ammonia. The residuum which re- mained after digestion with absolute alcohol was dissolved in a great measure in boiling spirit of wine, leaving behind a viscid brown substance, in appearance and smell completely resembling that which is obtained in the formation of leucine and tyrosine from the decomposition of the pro- teine principles by acids. The spirituous solution when evaporated left behind a syrup, which became converted into a solid crystalline mass, from the separation of crystals of leucine. Tlie urine thus contained the same (or as regards the amorphous mat- ter, ])erhaps onlv similar) substances as those which result from the arti- ficial decomposition of the proteine compounds; whilst the urea, which, under normal circumstances, constitutes the chief product of the meta- morjihosis of the tissues, was wholly absent. The blood in the heart and in the vena? cava3 contained a small quan- tity of leucine, and larger quantities Avere found in the cerebral substance, the liver and the spleen: these last organs contained a much larger amount than corresponded to wliat was found in the blood. Not a trace could be detected in the muscular substance of the glutaei muscles. The OT^ DISEASES OF THE LIVER. 147 chemical examination of the pancreas met with an accident. Thus the liver and the spleen were the sole organs in which considerable accumula- tions of these substances had taken place; they are the organs which, to- gether with the lymphatic glands and the pancreas, represent the chief formative masses of the body. The presence of a considerable amount of tyrosine in the liver, while in the spleen it could not be detected with positive certainty, favored the supposition that this substance owed its origin in great part to the destruction of the hepatic parenchyma. Observation No. XVI. Jaundice in the seventh month of pregnancy . — Severe pains in the Head. — Great restlessness. — Abortion. — Vomiting of black fluid. — Obsti- nate Constipation. — Coma. — Petechioe. — Death eight days after the commencement of the Jaundice. — Acute Atrophy of the Liver. — Small Spleen. — Fatty degeneration of the Kidneys. — Abundance of Jjcvxiine and Tyrosine in the Urine. — Urea and Leucine in the Blood. Rosalie Kienert, aged 35, was admitted on the 24th of September, 1857, into All Saints' Hospital, and died there on the 28th of the same month. The patient was a servant of robust constitution, who had previously been healthy, who, five years before, had undergone a good confinement, and who was now in the seventh month of her second pregnancy. Up to the 20th of September, she had followed her employment as a nursery-maid, and had first complained during the last week of a feeling of tightness and pressure in the scrobiculus cordis. Early on the morning of the 20th, when on the point of going to her work, she was seized with a violent rigor; and at the same time violent pains in the head, loss of appetite, and jaundice of the face made their appearance, for which complaints she first sought medical aid on the 24th. On this day the patient came on foot to the Institution, in a violent fever, and scarcely in a condition to drag her- self along; she blamed the treatment she had experienced at the hands of her master as the cause of her illness. Her consciousness was unimpaired, but she was very restless, and kept constantly rolling about in bed from side to side; she suffered from violent pains in the forehead and occiput; the countenance was pale, and of a moderately yellow tinge; pupils normal; pulse 120 and soft. Vomiting occurred from time to time, by means of which undigested food, such as crude plums, was thrown up. The bowels were confined; the abdomen was greatly distended by tympanites; no hepatic dulness could be made out; the urine was brown, and loaded with the coloring-matter of bile. Was ordered muriatic acid. The night was spent in loud groans without sleep. Early on the 25th, labor-pains came on, and about 1 o'clock, the pa- tient was delivered of a six months' foetus, which showed no traces of jaundice; during delivery there was a severe rigor and repeated vomiting of a blackish-gray grumous fluid; the patient complained of constant shiv- ering, groaned much, and from time to time screamed out loudly. On the 26th, there had been no sleep during the night; the conscious- ness was unimpaired; there was frequent vomiting of black fluid; and not- withstanding the administration of compound infusion of senna, no evacu- ation of the bowels had taken place. The hepatic region was tender upon firm pressure; no dulness could be made out either here or in the splenic 148 A CLINICAL TREATISE region. Pulse small and weak, 104 to 108. Respirations 24. Great apathy. Towards evening this apathy increased, until it merged into coma, from which the patient could not be roused. The vomiting of black fluid con-] tinued; no stool; lochial discharge scanty. There were petechias upon the skin of the lower extremities; pulse 104, small. The urine, which was drawn off by catheter, was free from albumen, rich in bile-pigment, and deposited, upon standing, a dark reddish-brown sediment. The hepatic dulness was searched for in vain, notwithstanding that the abdomen was soft, collapsed, and painless: the vomiting of black matter continued dur- ing the patient's unconscious condition; the skin was dry and cool. Towards evening, the respiration became stertorous. At 4 o'clock on the morning of the 28th, death ensued amid symptoms of acute cedema of the lungs. During the last two days of life no internal remedies were admin- istered, as all ingesta were immediately rejected from the stomach. Autopsy, 12 hours after death. The inner surface of the skull-cap was covered with osteophytes; and at many places was firmly adherent to the yellow-colored dura mater. The pia mater and substance of the brain were moderately congested and nor- mal. The mucous membrane of the bronchi v/as pale and covered with mucus; both lungs were very oedematous, but otherwise normal. The pericardivim contained about an ounce of yellow serum; numerous ecchy- moses were observed beneath the epicardium; the muscular tissue and the valvular apparatus of the heart were healthy; the cavities of the heart had their lining membrane jaundiced, and contained a considerable quan- tity of firmly coagulated reddish-brown blood. The mucous membrane of the oesophagus, the epithelium of which was slightly peeled off, was cov- ered with a black pultaceous material, which was found accumulated in large quantity in the stomach, and extended thence throughout the whole of the small intestine as far as the ileo-ca?cal valve. Numerous normal blood corpuscles were detected in it by the microscope. The mucous membrane of the stomach was very relaxed, and strewn over with puncti- form ecchymoses; the mucous membrane of the small intestine was pale and anoeniic ; solid gray fjccal matter was found in the cnecum and colon. The mesenteric glands were unaltered. The kidneys were very large and soft; their cortical substance was colored grayish-yellow, and their glandular epithelium was in an advanced stage of fatty degeneration. The urinary bladder contained a large quantity of dirty-yellow acid urine free from albumen. Nothing abnormal was found in the genital organs, with the exception of the traces of the abortion. The spleen was small, 4 inches long, 2^ broad, and f thick; anaemic, and of normal consistence. Its weight amounted to 0.11 kilogr. (4 oz. avoird.) The liver was much atrophied, and principally in its thickness; its riffht lobe was six inches long and equally broad; the left, 5-J- long and 3|- broad; the thickness of the right lobe amounted to 1^ inch, of the left to 4-. The entire weight of the organ, together with the gall-bladder and the trunks of the vessels, was 0.82 kilogr. (1.8 lb. avoird.); the weight of the body being 44.5 kilogr. (1)8. 104 lbs.), made the relative weight of the liver to that of the body as 1 to 54.2; there was thus a diminution in the weight of the liver by nearly one-half. The consistence of the flattened gland was soft, and at some places was almost pultaceous; its color was a ON DISEASES OF THE LIVER. 149 brownish -yellow; in the right lobe the branches of the hepatic vein were loaded with blood, which at some places appeared to be extravasated. The outer surface, especially of the left lobe, presented a wrinkled, finely- granular character, owing to the hepatic cells having disappeared at some places, and the parenchyma having collapsed; the depressed parts corre- sponded exactly with the circumference of the lobules. The peritoneal cov- ering was at such places opaque and thickened. The hepatic artery appeared large; but nothing abnormal was observed in the trunk of the portal vein. Injection of the branches of the portal vein could only be made to pass along imperfectly — a remark which was still more applicable to the hepatic artery; the injected matter penetrated readily into the ramifications of the hepatic vein, but almost everywhere it avoided the tissue at the central part of the lobules, and nowhere reached the capil- laries of the portal vein. On making fine sections of the tissue and dry- ing them, its structure could be examined more accurately and traced farther. As far as the periphery of the lobules, the ramifications of the portal vein were completely filled with the injection, but the further pas- sage of this into the capillary network was obstructed; only at a very few places was this network partially filled. The substance injected into the hepatic vein penetrated as far as the central veins of the lobules, which appeared unusually large, but only entered a short way into the capillaries in the central parts of the lobules, soon forming diffuse extravasations. A broad rim of oil globules was seen to surround the branches of the por- tal vein, whilst accumulations of bile-pigment, partly granular and partly diffuse, surrounded the central veins of the lobules. The hepatic cells were in some places still normal, and contained in their interior oil glob- ules or coloring-matter; but, at other places, they were found to have be- come disintegrated into a finely -granular detritus. Thus the morbid pro- cess had not advanced so far as in the last case. The bile ducts were per- vious and contained but little secretion. The urine, as well as the blood from the right side of the heart and the venfE cava^, were subjected to a closer examination. The urine, which had been passed twenty-four hours before death, was very acid, and deposited a thick yellowish-brown sediment, consisting, in a great measure, of urates, but containing, in addition, large yellow crys- talline masses of tyrosine. The urine was further examined according to the method already described. It contained a considerable quantity of urea, and much leucine and tyrosine, together with viscid extractive mat- ter. In this respect, the urine passed shortly before death differed from that which was collected from the bladder at the autopsy. In the latter there could only be detected an extremely minute trace of urea, and only a few crystals of nitrate o'' urea could be found, even with the microscope. The residuum, after evaporation of the urine, consisted of globules of leu- cine, intermingled with crystalline masses of tyrosine. Both substances were isolated and purified,' so there could be no doubt as to their iden- tity. ' The detection of leucine in the urine is not unfrequently rendered difficult, from the circumstance that the extractive matters entirely prevent th^ formation of crys- tals, and tlie condensed extracts remain for days of the consistence of syrup. One generally .succeeds in removing this impediment by digesting the extract for a long time with cold absolute alcohol, which gradually dissolves away the extractive mat- ter : by means of boiling spirit of wine the leucine cau afterwards be obtained in the crystalline form and purified. It is best to remove previously the principal portion of the extractive matter, by means of acetate of lead. 150 A CLINICAL TREATISE The blood also contained much leucine, and, what appeared impor- tant, a considerable quantity of urea. The latter was not only obtained as crystals in the form of nitrate and oxalate, but was also separated in a pure state. In the case before us, death took place before the cessation of the lo- cal functions of the liver, and before the disintegration of the glandular cells was complete, owing to the persistent and profuse haemorrhage from the stomach. Hence it was, that the urine secreted twenty-four hours before death still contained a tolerably large quantity of urea, whilst this had completely disappeared in Observation No. XV., in which the morbid process was more advanced. In other respects, the results of the two ob- servations coincided. The urea which disappeared from the urine, accu- mulated in the blood; there was no impediment, therefore, to the forma- tion of this substance, but only to its elimination. We see here, that without the existence of albuminuria, and without any remarkable dim- inution in the quantity of urine, the excretion of urea may be completely arrested. The only cause of this obstruction which could be found on the part of the kidneys was fatty degeneration of the glandular epithelium, the importance of which for the due performance of the renal functions is hereby shown; whether other causes co-operated cannot, in the present state of our knowledge, be ascertained. The quantity of urates going along with the absence of urea appeared remarkable. Can it be supposed that the conditions necessary for the secretion of urates are different from those under which urea is formed ? It is obvious, that the retention in the blood of the constituents of the urine may have favored the supervention of typhoid symptoms. Observation No. XVII. Si/}7iptoms of slight Catarrhal Jaundice, lasting fourteen days. On the fifteenth day, sudden maniacal delirium , haemorrhage from the iStomach ajid jDoicels, and Death. Atrophy of the Liver; its secreting cells partly disintegrated, and partly in a state of fatty degeneration. Anna Paul, aged 20, a maid-servant of robust constitution, was ad- mitted on October 17th, 1853. With the exception of slight attacks of cardialgia, she had always before been healthy; but for fourteen days she liad complained of listlessness, loss of appetite, and tendency to con- stipation; along with which symptoms there was slight jaundice of the skin. Upon admission, the epigastrium was found distended and painful; there was no enlargement of the spleen; the hepatic dulness in the mam- mary line measured 5 centimetres (2 inches); the tongue was dry; bowels constipated for two days. Pulse 104, small and weak; urine abundant, of a yellow color, but without the reaction of bile-pigment. The patient was inseTisihle, but not delirious. She was ordered dilute muriatic acid, and an enema of compound infu- sion of senna. At 7 in the evening, noisy delirium suddenly set in; the pulse was ] 40, and small; extremities cool. About 9 o'clock there was vomiting of black tarry matter; at 12, there were violent maniacal symptoms, and ON DISEASES OF THE LIVER. 151 the pulse was quite imperceptible. Death took place about 5 in the morning. Autopsy. Brain and lungs normal; numerous ecchymoses upon the epicar- dium. The heart contained dark fluid blood, with gelatinous fibrinous flakes. The mucous membrane of the stomach and small intestine was covered with black blood; the membrane itself was intact. Hard gray fasces were found in the rectum. • The spleen was slightly enlarged, soft and congested. The liver was small, flattened, and dry; its cut surface presented a uniform ochre-yellow color; its consistence was at some places dimin- ished, at other parts normal. The hepatic cells were loaded partly with fat and partly with pigment; in the softer portions of the organ they were entirely absent; here, nothing could be seen but oil globules and brown granules. Obsebvation No. XVIII. Abdominal Typhus. — Profuse Epistaxis. — Violent Delirium. — Jaundice on the fifth day. — Disappearance of the hepatic dulness. — General muscular tremors. — Coma. — Death on tlie eighth day. Small, shrivelled liver, with partially disintegrated cells and empty bile ducts. Tumefaction of the Spleen. Deposits in Peyer's patches, and in the solitary glands of the Ileum. Gottlieb Heumann, a clerk, aged 18, came to the Hospital on Novem- ber 18th, 1851, and died on the 26th. This young man, after having felt out of sorts for some days, was seized on the 16th of November with severe rigors and heat of skin, fol- lowed by headache, general depression, and bleeding from the nose. He was ordered chlorine. On the 18th, the haemorrhage from the nostrils re- turned to such an extent that plugging became necessary. Was ordered creosote. So early as the 19th, there was delirium and great restless- ness; the stools were thin and pale. On the 20th, there was protracted delirium, with excitement. The spleen could be distinguished extending one inch beyond the margin of the ninth rib. Tongue dry; profuse per- spiration: pulse 120. On the 21st, slight jaundice made its appearance; the pulse was 114, and very weak; the strength was failing; the hepatic dulness in the mam- mary line was slight, and in the sternal line, absent; two or three thin, pale stools in the day. He was ordered muriatic acid with ether, in de- coction of althaea. On the 23d, there was a severe rigor, lasting for two hours; great rest- lessness, and dyspnoea. On the 2-ith and 25th, there were several attacks of tremors not un- like rigors; respirations 42; severe pulmonary catarrh; extensive rhonchi. Pulse 120, tremulous, and very weak. Stools involuntary. Was ordered benzoic acid, with camphor. On the evening of the 25th, pulse 136; respirations 56; large drops of 152 A CLINICAL TREATISE perspiration; complete loss of consciousness; persistent tremors of the ex- tremities. Death on the 26th. Autopsy on the Hth. The abdominal cavity only could be opened. Liver: the left lobe was visibly atrophied, with thin, sharp margins, and great diminution of its thickness; the margins of the right lobe were likewise very sharp; the entire organ was soft and shrivelled {ivelk). The cut surface was pale-brown, completely homogeneous, with no ap- pearance of lobules; nowhere did any colored fluid escape from the bile ducts upon pressure; a small quantity of whitish whey-like fluid was found in the gall-bladder, the mucous membrane of wliich was not at all yellow. The glandular cells were in part disintegrated; some of them were very pale, and several were filled with fat. The spleen was enlarged, very soft and dark. The kidneys were of normal size, soft, and anfemic. In the small intestine, there were white submucous deposits in Peyer's patches, and the solitary glands, the more extensive the nearer the ileo- caecal valve Avas approached. There was no abrasion of the surface of the mucous membrane; the mesenteric glands were greatly enlarged, of a bluish-red color, and partially infiltrated with gray deposit. It may be a matter of question whether this case, for the accurate notes of which I am indebted to my friend Ruble, is to be regarded as one of acute atrophy of the liver, or as one of severe typhus, complicated with jaundice. The great diminution in the size of the gland, the disintegra- tion of a portion of the hepatic cells, and the disappearance of the bile, have induced me to bring forward the case in this place. It is impossible to draw a sharp definition between the two conditions just mentioned. The difTuse infiltration of the hepatic parenchyma, and the impaired secreting functions of the organ, which, as above observed, occur not un- frequently in severe cases of typhus, are abnormal states, which differ from acute atrophy, with complete arrest of the hepatic functions, more in degree than in nature. In both cases there is an exudation, which de- ranges tlie nutrition and the functions of the gland. A case of typhus, in which the atropliy of the liver was even farther advanced, has been de- scribed by Buhl (<'/>. cit.). IT. ANALYSIS OF THE SYMPTOMS. In order to determine with accuracv the symptoms which arise in con- sequence of acute ati'ophy of the liver, it appears to me necessary to make a detailed analysis of the materials hitherto collected. The number of reliable observations which I have thought might without hesitation be employed for this purpose, amounts to 31. The description of some of these cases is incomplete, and is, therefore, not applicable to the determi- nation of every question. 1. TJie Premonitory Siymptoms. Those were described in one half of the cases, and usually consisted of those df raiiaements which arc met with in acute catarrh of the stomach and bowels occasionalh* of rheumatic affections; upon these symptoms ON DISEASES OF THE LIVER. 153 jaundice supervened, which, in its characters, was in no way distinguish- able from simple jaundice until the symptoms of impending danger sud- denly broke out. In most cases, the duration of these premonitory symp- toms amounted to from three to five days; but in many cases, to from two to three weeks and upwards. 2. The Skin. This was invariably jaundiced, although the color seldom attained a high degree of intensity. So far as my own observations extend, this color did not appear at all conspicuous. As a general rule, it commenced in the upper half of the body, on the face and neck; it extended over the lower extremities less frequently, and was here scarcely observable. Along with the color, the skin was usually cool, dry, and inactive; ia noie of my own cases was any elevation of temperature observable. x\Hson and Bright likewise make particular mention of this circum- stance. It is only at the commencement, during the premonitory febrile stage, and afterwards for a short period in the stage of great nervous ex- citement, during the restless delirium and convulsions, that the tempera- ture has been observed to be elevated.' In the advanced stage of the disease, the cutaneous system not unfre- quently participates in the htemorrhages which proceed from various parts of the body, and especially from the mucous membranes: petechia; and large ecchymoses, of a reddish-brown or black hue, become developed. These are by no means of constant occurrence, being wanting in two- thirds of the cases. 3. The Organs of Circulation. The heart's action presents great variations in acute atrophy of the liver. If there are premonitory febrile symptoms, the pulse, upon the ap- pearance of the yellow color, becomes less frequent and remains in this condition as long as the jaundice retains a simple character. Not until the abnormal nervous symptoms become prominent does the rapidity of the pulse begin to increase, and it then rises from 50 or 60 to 90 or 100, or upwards. Remarkable variations in its frequency are at the same time observable; for a brief period it rises to 110, 120, or 130, soon afterwards to fall again to 80 or 90. This fluctuation, which is equally observed in reference to the size and hardness of the pulse, may be repeated several times in the course of a few hours. Not until incipient cerebral paralysis supervenes does the increased frequency continue of a uniform character; then it sometimes reaches 140 to 150 beats, whilst its character is small, thready, and intermittent.* To these abnormal conditions of the cardiac and vascular functions are not unfrequently superadded hjemorrhages, which usually take place simultaneously from various parts of the body; they were observed in one > Wunderlich {Handb. der Pathol, und Therapk, 2te Aujl., Bd. IV., S. 655) states, that he has observed in several cases of malignant jaundice a sudden rise from the normal temperature up to o-t cent. (99. 2' Fahr. ): there is no statement, however, to show what form of iralig'uant jaundice he alluded to. '-' Even the earlier observers were astonished at this variable condition of the pulse. Vercelloni {Bianch'\ loc. cit., II., 794) spe::ks of it as "pulsus insequalis turn quoad robur, turn quod numerum vibrationum." 154 A CLINICAL TREATISE half of the cases. They were met with most frequently from the mucous membrane of the stomach and bowels, in the form of haematemesis and melfena (ten times). Uterine haemorrhages were equally common; they were especially observed in the case of pregnant females, and then most frequently induced abortion. Petechiae, large ecchymoses of the skin, and epistaxis were of less frequent occurrence; renal hfemorrhage was only present in exceptional cases [BuJil). Other haemorrhages were almost always found in the dead body, which it was impossible to recognize dur ing life. Among these may be especially mentioned those which took place from the portal system, extravasations between the folds of the mesentery, in the omentum, upon the serous surface of the bowel, hfemor- rhagic infarctions of the spleen, and likewise, although less frequent, ex- travasations beneath the pleuras and the pericardium, and upon the mu- cous membrane of the pharynx and bronchi, haemorrhagic infarctions of the lungs, &c. 4. The Respiration. The respiration remains unaffected during the first stage of the disease; the mechanism of the respiratory movements is unaltered, and their fre- quency bears a normal ratio to that of the pulse, oris only slightly at vari- ance with it. It is only in the later stages, when the oscillations in the heart's action, just mentioned, commence, that the respiratory motions, at least in many cases, are wont to be abnormal, and the breathing becomes sighing or stertorous. In such cases, a short inspiration, accompanied by a groaning noise, is followed by a rapid expiration, and then there is a long pause, similar to what is observed in animals in which the pneumo- gastric nerves have been divided. Structural changes of the air-passages, capable of impairing the functions of the lungs, seldom existed in the cases recorded, and it was only in excey^tional instances that there were found hiijmorrhagic infarctions and sub-pleural extravasations accompany- ing hcemorrhages in other parts of the body. 5. The Organs of Digestion. These always undergo important functional changes. The premonitory symptoms usually are ushered in by gastric derangements, loss of appe- tite, oppression in the prai'cordiura, nausea, furred tongue, constipation, &c. ; when there is no premonitory stage, these symptoms usually make their appearance on tlie outbreak of the jaundice. Among the most im- portant symptoms belonging to this group may be mentioned, in the first place, abdominal pains, which were observed in three-fourths of the cases. They are situated sometimes in the epigastrium; at other times, and most frequently, in the hyj^ochondria, especially the right, corresponding to the region of the liver. Pressure in this place gives rise to marked indication of pain, which is even observable during coma, from the distortion of the countenance. 1'he pains also come on spontaneously; and the patients complain, especially during the first stage of the malady, of an uneasy sensation in the cardiac region. Although the abdominal walls are very ten.s(^ and tender, there is usually no fulness present in the hypochondria. Tlio results of percussion are of much greater diagnostic importance than the jiaiii, which in many eases is completely absent. Percussion sliows a rapid diminution in the volume of the liver, commencing with the ON DISEASES OF THE LIVER. 155 left lobe and extending towards the right. Usually the hepatic dulness soon disappears entirely, because the organ, constantly becoming softer, owing to the disease of its tissue, collapses, and is pushed towards the vertebral column by the intestines distended with gas. In the same pro- portion as the liver is atrophied the spleen is enlarged, and is the seat of tenderness, on pressure, in the left hypochondrium. It is only in rare cases that the increase in volume of the spleen cannot be made out, owing to the organ being inaccessible to percussion, from old adhesions fixing it in the hollow of the diaphragm, or owing to there being no enlargement at all. The latter may be the case when there is thickening of the splenic capsule, which prevents the organ enlarging, or when there is profuse haem- orrhage from the stomach and bowels to such an extent as to drain the portal system. Along with these changes in the volume of" the liver and spleen, which, with some care, are easily recognized, repeated vomiting is usually ob- served at an early period. The vomited matters have in most cases con- tained at first gray mucus, and occasionally bilious matter, but after a time they have consisted of a grayish-brown or black grumous fluid, the color of which is more or less dark, according to the severity of the gastric hsem- orrhage. When the hasmorrhage is slight, I have noticed, mingled with the mucous fluid, numerous brown flakes, consisting of decomposed blood, which Morgagni observed long ago, and designated as a " materies sub- obscitrus.^'' Almost invariably there has been obstinate constipation, which could only be overcome by strong purgatives; the stools have been dry and clay- colored; and, at a later period, they have assumed in many cases a dark tarry aspect, in consequence of intestinal haemorrhage. 6. The Urinary Organs. The urine according to my observations, has always been secreted »« normal quantity; but in the more advanced stages of the affection it has been necessary to draw it off by the catheter, for the purpose of examina- tion, otherwise, it has passed off involuntarily. It was always of acid re- action; its specific gravity varied from 1012 to 102-i; at first it only in- distinctly presented the reaction of bile-pigment, and it was not until a later period that this could be detected with certainty. The remarkable changes in the composition of the urine, the appearance in large quantities of leucine, tyrosine and extractive matters of a peculiar nature, together with the gradual disappearance of the urea and phosphate of lime, as was found to be the case in Observations XV. and XVJ., are conditions wliich hitherto have been found in no other disease. These properties of the urine indicate the existence of deeply important, although long unrecog- nized, abnormal states, of the metamorphosis of matter, and they furnish (provided further observation shall, as I have no doubt, show them to be of constant occurrence) no small insight into the transformations which take place in the albuminous principles, in cases where the functions of the liver are arrested. The peculiarity of the urine of most value in a clinical point of view is the deposit, upon exposure to the cold, of a green- ish-yellow precipitate, which, even with the naked eye, and still more read- ily upon microscopic examination, can be recognized as differing from all other deposits; to this may be added, the appearances presented by a 156 A CLINICAL TREATISE drop of the dried urine. (Vide Frontispiece.) Further evidence can only be obtained by careful chemical analysis. It ought also to be mentioned, that occasionally small quantities of albumen have been found for a short period in the urine. 7. The Nervotcs System. Abnormal conditions of the nervous system have been observed in every case as essential, characteristic symptoms; and they have almost inva- riably presented the same general characters, although in some ca&es there have been sundry marked deviations. In most cases we can distinguish two stages, that of excitement, and that of depression, the former of which is characterized by delirium and convulsions, and the latter by a progress- ively increasing coma, gradually verging into cerebral paralysis. Only in rare cases (in one-sixth of the whole number), was the stage of excite- ment absent, the patients falling at once into a state of typhoid pros- tration, which passed into unconsciousness, somnolence, and finally, into coma. The nervous derangements are ushered in with severe headache, ac- companied by a gloomy, irritable temper and restlessness. These symp- toms are soon followed by delirium, which is usually noisy, and raging, but occasionally shows itself in the form of quiet, harmless wandering. The patients throw themselves about in a restless manner, moan loudly, and from time to time utter an inarticulate cry; not unfrequently they fall into maniacal paroxysms.' Convulsions accompanied the delirium in ten cases, or in one-third of the total number of observations; in some instances they extended over the entire muscular system, like those of epilepsy, and not unfrequently commenced like these with a shrill cry; in other cases again, they consist- ed of general muscular tremors, resembling a rigor; while, lastly, in some cases, they appeared as partial twitchiiigs of the muscles of the face, neck, or extremities, or in the form of hiccup, grating of the teeth, &c. Tris- mus, and even sometimes tetanic spasms, have been observed in a few cases. Towards the termination of the disease, the delirium and convulsions, as a general rule, have given place to stupor, which in a short time has merged into the deepest coma, from which no shouting nor shaking could rouse the patient. The characters of the pupils have been by no means constant; in many cases they remained of normal size, and reacted with light, as in my own observations, and in those of Frey, &c. ; in other cases again, they wore dilated and immovable, and in very rare instances, con- tracted. Yellow vision occurred in exceptional cases only. In most cases, the nervous derangements appeared simultaneously with the jaundice; and they usually attracted the attention of the observer sooner than the slight jaundiced-tint of the conjunctiva, and of the skin surrounding the al;e of the nose. Sometimes matters were diiferent, the ' This character of the delirium in jaundice appears to have been known to the ancients. Hippocrates {ad iJanocr.'ti/m phi'os. tjvst.) observes: — '"Qui ex pituita in- saniunt quieti sunt, qui vero ex l)ile hi verberant, raalefici sunt, neque quiescunt." Hippocrates further observes (iJc morbo xdcro : — '"Qui ex bile insaniunt clamosi, malicj-ni et mir.inio quieti sunt, semper aliquid intenipestivum faciunt." Ballonius oXmiEpidon. e]>hriuu\, lib. II., cap. 188) describes the delirium as "vox inarticulata, ejulatus magnus." ON DISEASES OF THE LIVEE. 157 jaundice lasting 2, 5, 8, 14, 17, or even 21 days, without any impairment of the nervous centres, until suddenly, the scene became transformed, and a train of symptoms betokening danger supervened. V. DURATION AND MODE OF TERMINATION. The symptoms just described usually run their course in a few days; in most cases the entire process terminates within the first week, but occa- sionally the disease is protracted to three or even four weeks. In such cases it is the apparently simple jaundice of the preliminary stage which is protracted. After the commencement of the characteristic symptoms, the disease almost invariably terminates in five days, and sometimes even in from 12 to 36 hours. In 3 of the 31 cases, the date of the commence- ment was unknown; in the remaining 28 cases, the fatal termination oc- curred : — during the 1st week 13 times. " 2d " 6 " « 3d " 5 " « 4th " 4 " The termination has almost invariably been fatal; this result has been so constant, that the few observations which have been recorded of a cure having taken place, must be regarded as of a very doubtful character, and the more so, as most of them have occurred at a time when only a few ex- amples of the disease had been collected, and when there was nowhere to be found any accurate account of it to confirm the diagnosis. Griffin ' mentions two cases, and Hanlon " one, which terminated favorably; Budd also makes mention of one case of cure, which took place notwithstanding the previous occurrence of bloody stools, pains in the hypochondria, hic- cup, and coma. In the year 1854, I treated successfully a lady, aged 40, for jaundice, associated with symptoms which favored the supposition that there existed incipient atrophy of the liver; still I would not venture to assert that this condition was really present. In this case, the jaundice was slight, and was accompanied by delirium and typhoid somnolence, the right hypochondrium was painful; the hepatic dulness was diminished and, in the epigastrium, had completely disappeared; the spleen was en- larged. The pulse varied between 88 and 104; the bowels were confined and the stools pale; there were repeated attacks of epistaxis, &c. After eight days, these symptoms ceased, and the patient slowly recovered. The treatment employed consisted in drastic purgatives and mineral acids. When the anatomical lesions, from which this disease is thought to originate, have made considerable progress, and the larger portion of the hepatic cells have become disintegrated, one can understand that a cure can no longer be thought of. The prognosis is thus, under all circumstances, in the highest degree unfavorable. VI. — ANATOMICAL LESIONS. The structural changes, which we find on post-7vorteni examination to account for the derangements of the various functions just described, are ' Dublin Med. Journ., 1834, IV., 12. * Graves, Clinical Medicine. 2 ed., 1848, Vol. II., p. 255. 158 A CLINICAL TREATISE very diverse ; the only constant ones are lesions of the liver, next in order to which come those of the spleen. All other pathological states are in- constant; they may be absent without the symptoms during life undergo- ing any important alteration. Hence we regard the liver as the peculiar seat of the disease, from Avhich the derangements in the functions of other organs take their origin. The liver was in all 31 cases considerably atro- phied; the diminution in volume was estimated at one-third, one-half, or even two-thirds of the normal size. Accurate measurements and weights were, however, only made in a few instances. Bright saw the weight re- duced to 2 pounds, to 23 ounces, and in a third case, to 19 ounces: I have myself, in two instances, found the liver to weigh only 0.82 kilogr. (1 lb. 13 oz. avoird.), the relative weight to that of the entire body being as 1 to 68.5, and as 1 to 54.2, which indicated a reduction of more than one- half. The size of the organ is diminished in every direction, but especially in its thickness; the gland is flattened out. The capsule presents an opaque puckered appearance; the parenchyma is flabby and shrivelled [toelk), so that it is unable to bear its own weight, and folds up and col- lapses in front of the vertebral column. The cut surface of the organ presents at those places where the disease has advanced farthest, and these are usually in the left lobe, an ochre-yel- low or rhubarb-like color; the blood-vessels are here empty, and in most cases the outline of the lobules is no longer visible. At other places, whore the morbid process is at an earlier stage, some of the capillaries are filled with blood, and occasionallv there may be seen extravasations or their remains in the form of crystals of hncmatoidine. Between the lob- ules, which are encircled by the congested vessels, and separating them from one another, a dirty gravish-yellow substance is deposited. At a later period the capillary congestion recedes, the size of the lobules diminishes, and their color becomes vellower, whilst the relative amount of the intervening gray substance gradually increases. After a time, this gray substance disappears at those places where the atrophy of the gland is most apparent, and the organ assumes more and more a uniform yellow tinge, from which the outlines of the lobules by degrees completely disap- pear. As regards the vascular apparatus of the liver, no important alter- ations are observed in the trunk and branches of the portal vein; they contain a small quantity of thin blood; in the hepatic veins I have found bundles and masses of tyrosine crystals, along with normal blood corpus- cles. Attempts at injection have proved unsuccessful, the size which is injected into the hepatic and portal veins becoming extravasated, without penetrating into the capillaries, apparently because the delicate blood- vessels have lost their support, from the destruction of the secreting cells. In thin sections of the gland, the injection covild be distinctly seen to fill only the capillaries nearest the central vein, and then to escape into the pa- rench^-ma. The centre of the lobules appeared of a dirty-yellow color, and exhibited here and there brownish crystalline masses of leucine; at their periphery nothing but fiiie bluish-gray oil globules could be detected. Where the disease had run through its entire course, the hepatic cells were no longer visible; in place of them were found brown granules, and large particles of coloring-matter, oil globules, and isolated bodies similar to cell nuclei, often accompanied by needles of tyrosine and globules of leucine. It was only where the morbid process had been arrested at an early stage, that there could be seen isolated cells loaded with fat or pigment, and this was especially the case in the rounded margin of the right lobe. ON DISEASES OP THE LIVER. 159 In the seventeen most recent observations of acute atrophy of the liver, the disintegration of the hepatic cells was always made out; in the earlier cases the organ was not examined with this object in view. The gall-bladder was in most cases empty, containing only a small qxiantit}'^ of gray mucus, or a turbid, pale-yellow, rarely brown or green- ish, fluid. The bile ducts exhibited nowhere any impediment to the ex- cretion, and likewise contained no bile; their mucous membrane was in most cases of a gray color, and their calibre seemed narrowed. Along with the atrophy of the liver, the spleen, in most of the cases, was found considerably enlarged and congested; out of 23 cases in which this organ was carefully examined, in 19 it was enlarged, in 3 normal, and in 1 small. There are certain causes, such as thickening of the capsule, or profuse haemorrhage from the roots of the portal vein, which may ac- count for the non-appearance of the swelling. In some cases the mesen- teric glands were also found to be enlarged.' The stomach and intestinal canal present no important alteration of structure; the mucous membrane is here and there ecchymosed, but there are no losses of substance nor deposits in the solitary glands, or in Peyer's patches. The intestinal contents consist either of pale, dry faeces, or of black tarry matter, in which the microscope cannot detect any blood cor- puscles which have not undergone some change. The central organ and the larger trunks of the vascular system present nothing abnormal, with the exception of a jaundiced color of the lining membrane, and a flabby, shrivelled character of the muscular tissue of the heart. The blood is of various characters; sometimes it is dark-violet and incompletely coagulated, but at other times hard firm coagula of fibrin separate from it ; the number of colorless corpuscles is found to be increased in the blood in the right ventricle. The presence of large quantities of leucine and of urea, as in Observation XVI., is a much more remarkable circumstance." The extravasations of blood in various organs and tissues are also remarkable. These were seen in the larger number of the cases; they were most frequent in the parts from which the portal vein draws its supplies of blood, from the surface of the mucous membrane of the stom- ach and bowels, more rarely in the tissue itself of these organs, beneath the serous coat of the intestine, and between the folds of the mesentery and omentum; they were also observed in the retro-peritoneal areolar tis- sue, and beneath the pleura? and epicardium. The effusions into the se- rous cavities were often found tinged with blood. More rarely, haemor- rhages take place into the parenchyma of the internal organs, such as the lungs, kidneys, &c. The kidneys have not received the attention which they deserve. Besides the deposit of pigment dependent upon the jaundice, I have found the glandular epithelium infiltrated with granules, and. in most cases in a state of fatty degeneration, and the tissue itself flabby and shrivelled. The cases occurred for the most part among pregnant females, in whom Spaeth has made the same observation. Whether this abnormal condition is al- ways present remains uncertain. The peculiar changes in the urine, the disappearance of the urea from it, and the accumulation of this substance in the blood, and further, the temporary occurrence of albuminuria, point, however, to an important implication of the kidneys. ' Buhl ; and Observation \o. XVIII. ' Whether there were any other abnormal products present, such as the ammonia- cal salts, has unfortunately not been investigated. 160 A CLLS^ICAL TREATISE The central organs of the nervous system have inmost cases presented abnormal conditions. In some cases the cerebral substance has appeared softened; a hydrocephalic softening has been particularly observed in the central parts [Horaczek, Pleischl); hut it is still doubtful whether this condition is to be regarded, with Lebert, as the result of commencing putrefaction, or as a product of disease; at all events, this change in the consistence of the brain cannot account for the production of the nervous symptoms, as it is usually absent. The post-mortem examinations which I have myself performed have disclosed nothing abnormal in respect to the consistence of the brain, or to its amount of blood, even when death has been preceded by serious derangements of the nervous system. vn. — Nature of the Disease. We have now to construct a theory from the facts which have been observed ; we must endeavor to explain the morbid process which takes place in the liver, and to point out the connection in which it stands to the concomitant symptoms. Acute atrophy of the liver belongs to those obscure processes, as to the nature of which various opinions may be advanced, without its being possible for any one of them to obtain a general acknowledgment. The fact of the disappearance in a few days of one-half or one-third part of the original volume of a large glaiid abounding in blood, without any alter- ation in the blood-vessels leading to it, has a complete analogy in no other disease. Rokitansky, who was the first to give an accurate anatomical description of this affection of the liver, regarded the process as one of bilious liquefaction. An excess of the elements of bile, according to him, is formed in the blood of the portal vein, which, becoming separated, and pervading the entire vascular apparatus of the liver, causes destruction of the glandular substance by liquefaction. Such a mode of origin of the bile in the portal vein is opposed to our previous knowledge concerning the formation of this secretion, and, moreover, the increased secretion would not account for the destruction of the organ. Henoch and Von Dusch likewise refer the destruction of the hepatic cells to the action of bile. The former assumes the existence of a true polycholia, in consequence of which all the excretory ducts, even those of capillary fineness, become distended with secretion and compress the blood-vessels; hence arises a considerable impairment in the nutrition of the hepatic cells, which ultimately lead to their disintegration by falty metamorphosis. Von Dusch is of opinion that the disease proceeds from paralysis of the bile ducts and Ivmphatic vessels, which gives rise to an infiltration of the organ witli bile, and, through this, to a solution of the cells. We cannot agree with either of these views, first, because no accumu- lation of bile can be observed to precede the atrophy; and secondly, be- cause, even if such were the case, it would not account for the atrophy. Henoch's assumption, that a state of polycholia induces the morbid pro- cess, does not harmonize with the symptoms of the preliminary stage, or, when this is wanting, with the commencement of the disease itself, inas- much as the evacuations from the first contain but little bile; moreover, it cannot well be conceived, how an abundant formation of bile can distend the ducts as far as their capillary commencements, so long as there is no impediment to its excretion. The paralysis of the bile ducts and lym- ON DISEASES OF THE LIVER. 161 phatic vessels assumed to exist by Von Dusch, is purely hypothetl !al, and is not sufficient to account for a stoppage of bile, because the ducts at their commencement contain no muscular fibres, and the absorption of bile takes place more especially by the blood-vessels. But, even admit- ting that the atrophy was preceded by a stoppage of bile, this would afford no explanation of the rapid disappearance of the parenchyma of the liver, because, in cases where the ductus choledochus is obstructed, the hepatic ducts are not unfrequently filled and distended with bile during many months, and the hepatic cells are saturated with secretion, without any condition resembling acute atrophy resulting.' The experiments, there- fore, by which Von Dusch has endeavored to prove that bile exercises a solvent action over the hepatic cells, appear to be of doubtful value in framing a theory of the disease under consideration; moreover, on repe;it- ing these experiments, I have ascertained that the hepatic cells may be immersed in bile for whole days without undergoing solution. Buhl regards the disease as analogous in its nature to typhus; the disintegration of hepatic cells he attributes to the same cause as the con- comitant haemorrhages, namely, to the marked weakening of the heart's action, and to the rapid decrease of the peripheric metamorphosis of mat- ter. The changes which the liver undergoes in typhus, pyaemia, &c., he considers as the commencement of acute atrophy. In opposition to the theories just mentioned, there is another, which attributes acute atrophy of the liver to a diffuse inflammation of the gland. This theory was first enunciated by Bright, who described cases of the disease under the appellation of hepatitis; in recent times, Engel, Wedl, and Bamberger have subscribed to it, and have explained the destruction of the cells by a fatty degeneration arising from an acute exudation-pro- cess. Although I have some hesitation in identifying the destruction of the hepatic cells with fatty degeneration, — because in the case of other glands, such as the kidneys, fatty degeneration of the epithelium does not produce such a rapid and general destruction of the cells, and especially because, in acute atrophy of the liver, the fat can only be seen deposited in the circumference of the lobules, whilst the destruction of the ceils is found to extend as far as the central vein, — still I cannot but adhere to this view in so far that, according to my experience, an exudation-process constitutes the starting-point of the disease. On close examination of a liver which is undergoing acute wasting, portions are found mostly in the right lobe, in which the morbid process has not run its entire course. Irk such places, changes of structure may be detected, which appear to prove- that the destruction of the glandular elements, and the collapse of the- parenchyma, are preceded by hypersemia and exudation. We here ob~ serve, not merely a remarkably congested condition of the capillaries, hut,, in the circumference of the lobules, broad gray bands, consisting of finely- granular matter with isolated cells undergoing disintegration, whilst the cells nearest to the central vein still continue normal, except that they are infiltrated with bile. At a later period the congestion disappears, the gray exudation matter is gradually removed, and the yellow debris of the secreting tissue becomes more closely aggregated; so that, in addition to the progressive atrophy of the organ, the outlines of the lobules are at last quite obliterated. The destruction of the cells as a result of exuda- tion is partly owing to the fact that this is deposited in a close vascular ' Sec Observations V. , YI. , and YIL Vol. L— 11 162 A CLIinCAL TREATISE network, where any effusion soon removes the necessary conditions of nu- trition, and partly to the cell-walls being delicate, and the contents of the cells prone to decomposition. The bile ducts at their origin are compressed at an early period by the exudation at the periphery of the lobules; as a consequence of this, the secretion formed in the central portion of the lobules stagnates, and passes into the central veins, and so into the general mass of the blood. It is in this way that jaundice comes to make its appearance, while the ochre-yellow color of the liver and the pale mucous lining of the empty bile ducts owe their origin to the same cause. Against the supposition that an exudation-process lies at the foundation of acute atrophy of the liver, it has been urged that no hypersemic enlargement of the organ can be detected during the progress of the disease. This objection is of small weight, because the liver has rarely been closely examined previous to the appearance of the jaundice, and because no remarkable enlargement of the organ is necessary for the occurrence of diffuse exudation, and the less so, as this does not usually attack the entire gland at one time. Another question which we must here endeavor to answer is: — how are the symptoms which accompany the disease connected with the struc- tural changes found in the liver ? It has already been shown in what manner the jaundice arises; it is a more difficult matter to explain the mode of development of the nervous symptoms, the hasmorrhages and the tumefaction of the spleen. I believe that the abnormal nervous symptoms, of which no explana- tion is furnished by an}^ morbid appearance of either the brain or its mem- branes,' must be referred to changes in the composition of the blood. I do not refer here to the presence of the copstituents of bile, as to the harmlessness of which I have convinced myself by a long series of injec- tion-experiments; but I attribute the cause of the blood-intoxication to the complete arrest of the hepatic functions from the destruction of the se- creting- cells, and to the derang-ement of the renal secretion. The tormer of these causes includes not only the absorption of bile, and the retention in the blood of the substances intended for the formation of this secre- tion, but also the cessation of the powerful influence which the liver exerts over the processes of metamorphosis of matter, and the simultane- ous passage of the disintegrated glandular substance into the blood. We are not acquainted in its entire extent with the influence exerted by the liver over the metamorphosis of matter; as yet we only know that the formation of sugar out of albuminous substances is a necessary link in the functional processes of the gland, and we infer from the existence of nu- merous other substances which have been observed, partly under normal, and partly under pathological conditions, such substances as xanthine, urea, inosite, leucine, tyrosine, cystine, &c., that the organ is intimately related in many ways to the metamorphosis of matter. The important nature of these relations is shown by the remarkable changes, which the urine — the general recipient of the chief ultimate products of this meta- morphosis — undergoes in acute atrophy of the liver. The urea, which is the normal product of the disintegrated albuminous tissues, as we have seen, gradually disappears and in its place, a large quantity of products which are foreign to healthv urine make their appearance. Its solid con- stituents consist almost exclusively of leucine and tyrosine, together with ' Bnhl is of opinion that here, as in typhus, we can always detect an acute atrophy of the brain. ON DISEASES OF THE LIVER. 163 a peculiar extractive matter; uric acid is present in tolerable quantity. It is doubtful what is the cause of the absence of urea. Is this substance really formed, although not excreted by the kidneys, or is the metamor- phosis of tissue so far altered that at last no urea comes to be formed as an ultimate product ? The considerable quantity of urea which is found in the blood, proves that its elimination is really stopped; still we must not conclude from this, that the formation of this product takes place in a normal manner, because we have no idea, not even an approximate one, as regards the amount to which it accumulates in the blood.' Thus far it must be regarded as an established fact, that acute atrophy of the liver induces very important abnormal conditions of the metamorphosis of mat- ter, and that during its progress substances circulate in the blood which are not met with in that fluid in a healthy condition. What it is which induces the symptoms of blood-poisoning is uncertain; that it is not leu- cine or tyrosine is proved, by injections of these substances into the blood of animals producing no derangements of the nervous functions. It is more probable that they are due to a retention of the constituents of the urine; but this point cannot be determined without further investigation. As regards the production of the splenic enlargement and the haemor- rhages, I believe that the former is to be accounted for, partly by the al- tered composition of the blood, and partly by the obstruction of the circu- lation in the hepatic capillaries, which lose their normal support in conse- quence of the disappearance of the cells; the circumstance of the hemor- rhages occurring chiefly in those parts from which the portal vein derives its blood, viz. : from the mucous membrane of the stomach and bowels, and between the folds of the omentum and of the mesentery, is in favor of the mechanical view of the matter. There must, however, be some far- ther reason to account for those hasmorrhages, which occur in other parts, such as the skin, &c. These have been attributed at one time to the de- bility of the heart's action, the general want of tone in the system, and the defective nutrition of the blood-vessels [J^uhl), at another time, to the deficient formation of fibrine (3fo?ineret), and at another, to an over-dis- tended condition of the blood-vessels in consequence of a deficiency in the secretion of bile. There is another explanation which appears to me more probable, namely, an abnormal attraction between the walls of the vessels and the blood which has become altered in its composition, from which arise obstruction and rupture of the capillaries. Bernard has already en- deavored to show, that the passage of sugar from the liver into the blood prevents the infiltration of the tissues, and promotes the circulation. In the cases before us, it is not only the formation of sugar which is arrested, but in addition to this, a whole series of substances pass into the blood, ivhich may not be without some influence over the production of the ' It may be mentioned that in yellow fever also a considerable quantity of urea has been detected in the blood. If we assume that the formation of urea ceases, prod- ucts should arise in its place, similar to those into which the albuminous substances are decomposed under the action of putrefaction, or upon the addition of nitric acid. The urea cannot be entirely replaced by leucine and tyrosine, because both these are poorer in nitrogen than albumen. It is thus clear, that along with these substances Btill another must be formed, containing a large proportion of nitrogen. Whether the amorphous matter which is found in large quantity in the urine corresponds to this, has not been ascertained with certainty; neither has any cau.se been assigned to prevent the farther transformation of this substance into urea. It is possible that the fer- ment matter, which experience shows to be contained in the liver, is indispensable to this further metamorphosis ; but the subject can only be cleared up by new observa- tions and direct experiments. 164 A CLINICAL TREATISE haemorrhages. It is obvious, however, that we do not possess a more complete proof of this theory than any of the others. VIII. ETIOLOGY. We are still without a clear insight into the mode of origin of acute atrophy of the liver; we can only enumerate in the meantime the circum- stances under which the affection makes its appearance, without being able to state the respective share which these causes play in individual cases, or to trace more closely their mode of operation. Unfortunately, however, the same remark applies to the etiology of most diseases. The disease is most frequently observed in the female sex: of the 31 cases, 9 were men and 22 females, so that the number of the latter more than doubled that of the former. Of the 22 females, one-half were attacked during pregnancy; consequently, more than one-third of all the cases were associated with this condition of the system, a circumstance which points to both of these conditions (sex and pregnancy) as predisposing causes. Nevertheless, acute atrophy of the liver is a rare affection, even in pregnant females; out of 33,000 cases, Spaeth found this complication present in only two instances. Very frequently during pregnancy, the kidneys and the liver become infiltrated with granular albuminous mat- ter, which gives rise to alterations in the character of their secretions, and to fatty degeneration of the glandular epithelium. Under certain conditions this process advances to diffuse nephritis and hepatitis; it is generally known how frequently this happens in the case of the kidneys, and also what are the symptoms which denote the presence of the renal affection; in the liver the process seldom attains such an advanced development, and here destruction of the gland is the result. Acute atrophy of the liver in pregnant females may be recognized by the fact that it is almost invariably accompanied by fatty degeneration of the kid- neys. That it is not mechanical compression, as Scanzoni thinks, to which the cause of atrophy of the liver is to be attributed in pregnant females, is shown by the period at which this affection makes its appearance; in most cases, it is from the third to the sixth month, sometimes it is the seventh, but it is rarely at a time when the uterus can operate mechanic- ally upon the liver. As regards age, the period of life between 20 and 30 seems most pre- disposed to the disease. Of the 31 cases, there were: — 6 between 10 and 20 vears of age. 20 " 20 " 30 " " " 3 " 30 " 40 " " 2 " 40 " 60 " " Cases of acute atrophy of the liver have also been described in chil- dren, but I know of no observation sufficiently detailed to find a place here. Of the special injurious agencies, which precede the outbreak of the disease, and which after its ajipearance co-operate with its exciting causes, the following are the most conspicuous. 1. Mental emotions. — In several cases the disease appeared in individ- uals previously healthy, so iininediately after a severe fright, or an out- burst of passion, that the influence of mental emotions could scarcely be OJf DISEASES OF THE LIVER. 165 doubted. The patients became immediately jaundiced, began to be delir- ious, and died in a few days. Such cases have been described by Vercel- loni, Morgagni, Ballonius, and others, 2. Venereal excesses, syphilis, the improper use of mercury, drunken- ness, and the other morbid influences arising from a dissolute life, have occasionally preceded the disease: still it is not certain that these morbid influences were connected with the disease as cause and effect, and it is still less possible to prove with certainty the influence of one of them apart from the others. 3. There would appear to be influences, of the nature of miasmata, confined to certain localities, which contribute to the production of the disease; at all events, we are led to believe in the existence of such influ- ences from the presence of the malignant forms of jaundice, in different members of the same family, or in other individuals living in the same house, examples of which have been recorded by Budd, GriflBn, and Han- Ion. It still, however, remains a question, whether these cases ought, or ought not, to be regarded as examples of acute atrophy of the liver; suffi- cient anatomical evidence on the point does not exist. A miasmatic ori- gin of the disease, as under certain circumstances seems at first sight probable, may indicate rather the existence of one or other of the forms of bilious fever, which supposition is favored by the frequency with which such cases have terminated favorably. 4. Typhus and the allied changes in the composition of the blood. — I have myself seen one case of acute atrophy of the liver proceeding from typhus, and Buhl has observed others, in which the mesenteric glands were enlarged in a similar manner to what they are in this disease. In such cases, there is a greater development of that infiltration of the hepatic parenchyma which we have already found to exist in typhoid jaundice. Usually no other cause can be detected, which can account for the origin of the morbid condition of the liver, and the etiology of the affection must be left for future investigations. IX. DIAGNOSIS. Acute atrophy of the liver is less easily recognized than it would ap- pear to be. It is very frequently mistaken for other diseases, particularly typhus complicated with jaundice, bilious fevers of various sorts, pyaemia, &c., and such mistakes can only be avoided by a careful weighing of all the symptoms. During the preliminary stage, a diagnosis, as a general rule, is impossible. When haimorrhages, violent headache, delirium, &c., are associated with jaundice, it then becomes a question whether, inde- pendently of the liver, there are local or general derangements present, which can or cannot account for these symptoms. Typhus is recognized by the symptoms which mark its progress, the roseolar eruption, the bronchial catarrh, the diarrhoea, and the wandering character of the de- lirium; bilious fevers, as a rule, are characterized by a more or less dis- tinctly remittent type, and by repeated attacks of rigors; pyaemia is dis- tinguished by rigors and by the presence of purulent deposits. Local diseases, such as meningitis, pneumonia, and peritonitis, which when as- sociated with jaundice and delirium, present a train of symptoms, resem- bling, as T have myself observed, those of acute atrophy of the liver, can usually be easily recognized by a careful examination of the individual organs. The characters observed by the liver itself are of greater impor- 166 A CLIiaCAL TREATISE tance in diagnosis, not so much the tenderness, which is now and then absent, as the diminution in volume, which advances rapidly, until at last the dulness on percussion completely disappears. The cautions which are to be observed in determining the dulness, have been explained in Chap. III. Of equal diagnostic value are the characters presented by the urine, the deposition of sediments of tyrosine, the crystalline forms which separate upon evaporation, &c. The importance of the remaining symptoms in diagnosis depends upon the frequency of their occurrence, a point which has already been discussed. Petechiae and epistaxis, which in typhus are of frequent occurrence, appear to be of less importance than vomiting of blood, as indications of acute atrophy. X. — TREATMENT. The results of treatment hitherto recorded, are, as has already been stated, of a hopeless nature; hence no approved empirical method exists. English physicians recommend emetics and purgatives, two classes of remedies the energetic action of which upon the liver certainly cannot be denied. According to Corrigan, the progress of the disease is arrested b}^ emetics, and according to Griffin and Hanlon, by drastic purgatives; in the case which I myself saw run a favorable course, purgatives and mineral acids were employed. This experience, small though it be, would be of great value if we could be sure that the observations really referred to cases of acute atrophy of the liver, which unfortunately is impossible, considering the uncertain nature of the diagnosis of the incipient stages of the disease. The lack of more direct experience must be supplied by general principles, and by the analogy of allied conditions. In the preliminary stage, the same principles of treatment are of service as in simple catarrhal jaundice; a more direct treatment is not called for, until symptoms denoting serious disease of the hepatic parenchyma mani- fest themselves. At the commencement, our object should be to remove the congestion and diffuse exudation; afterwards, when the atrophy has extended over most of the gland, no benefit can be expected from treat- ment. For the purpose just mentioned the stronger purgatives are es- pecially recommended, by means of which the congestion of the liver is most effectually relieved, such for instance, as senna, aloes, colocynth, &c., and they should be administered in such doses as to bring about pro- fuse evacuations. When there are severe pains in the liver, benefit will be derived from the application of leeches, cupping-glasses, and cold cloths, and in full-bloodod individuals from venesection, "When the sj'mptoms of blood-poisoning and haemorrhages make their appearance, the adminis-tration of the mineral acids is indicated, along with which purgatives may be continued, to keep up the action of the bowels. To check the vomiting we may prescribe ice, the magistery of bismuth,^ and small doses of the aqueous extract of nux vomica. Haemorrhages from the stomach and bowels require ice internally and externally, alum, gallic acid and similar astringents. When there are symptoms of nervous depres- sion, we must employ stimulants, such as ether, camphor, and musk; in such cases, however, it is seldom that we can look for any good result. In cases whei'e the diagnosis is doubtful, especially where the distinc- ' Trisnitrate. ON DISEASES OF THE LIVER. 167 tion between acute atrophy and bilious fever remains uncertain, I would recommend large doses of quinine dissolved in acids. Besides acute atrophy, there are other morbid processes, which, if they lead to complete disorganization of the liver, and consequently to aa arrest of its functions, may give rise to symptoms of blood-poisoning. Symptoms may appear under such circumstances which in most respects range themselves with those just described, but which differ in many points. Here, as in acute atrophy, there may be observed dangerous ner- vous symptoms, typhoid somnolence, delirium, coma, and convulsions, accompanied by petechias and ecchymoses of the skin, as well as by haemor- rhages from the mucous membrane of the stomach and bowels, and along with these symptoms we may find, in most cases, jaundice of a more or less intense degree; but on the other hand, the jaundice may be completely absent, the abnormal cerebral symptoms may be for the most part less vio- lent, and, moreover, the characters presented by the preliminary stage may be very different from those of acute atrophy, as, for instance, when the disease is preceded for a long time by symptoms of occlusion of the bile ducts, or by those of cirrhosis or fatty degeneration of the organ. Among the diseases of the liver, which may give rise to destruction of the glandular epithelium, may be mentioned, in the first place : — B. 1. Obstruction to the Flow of J^ile resulting from Impermeability of the Ductus Gholedochus and D. Hepaticus. In some cases, when this condition has lasted for several months, it gives rise to an atrophy of the gland, which in many points resembles acute atrophy. The organ diminishes in size and becomes soft and dry, the cells of the parenchyma which are infiltrated with bile become disin- tegrated into a finely -granular debris, mingled with oil globules and par- ticles of pigment, while at the same time large quantities of leucine and tyrosine may be detected. Obseevatio:n^ No. XIX. Cancerous Deposit in the Duodenum,. — Occlusion of the Ductus Choledo- chus. — Intense Jaundice. — Co?ivulsions. — Coma. — Death. Friedr. Bloch, a female, aged 58, who had been suffering for a long time from various diseases in Frankel's Asylum for Old People, was brought to the Jewish Hospital of this place on July 29th, 1853. The patient had her mental powers somewhat impaired, and was of a surly temper, so that it was impossible to ascertain any accurate history as to the mode of origin of her illness. On admission, she presented a series of symptoms, indicative of intense jaundice as a result of closure of the duc- tus choledochus. The woman was emaciated, and her dry wrinkled skin was colored at some places brownish-yellow, and at others olive-green; its temperature was low. The tongue was clean, and the appetite unimpaired. The bowels were confined, and the stools consisted of dry, clay-colored scybala. The urine was brownish-black, and deposited at one time a brick-red, and, 168 A CLINICAL TREATISE at other times, a yellow, sediment of uric acid. The pulse was 50 and weak. The left lobe of the liver extended about 5 centimetres (2 inches) beyond the margin of the false ribs, and reached upwards to a level with the lower margin of the sixth rib; the right lobe, which was elongated, and drawn downwards by means of a tight-lace constriction, extended 8 centimetres (3.15 inches) beyond the margin of the ribs. Close to the sternum, the hepatic dulness amounted to 9 centimetres (3.54 inches); in the mammary line it was 16 cent. (6.3 in.), and in the axillary line, 14 cent. (5.51 in.). The surface of the organ felt smooth; its margins were sharp towards the left side, but on the right side were somewhat rounded. Ten centimetres (4 inches) to the right of the umbilicus, and somewhat deeper, there lay a soft, pear-shaped tumor, the size of a duck's-egg, which was evidently the distended gall-bladder. No tumor capable of compressing the ductus choledochus could be made out upon palpation.' No hardness could be felt in the region of the pylorus, and of the head of the pancreas. There never had been any symptoms of colic from gall- stones. The patient was treated for a long time with tincture of colocynth, aloes, and such-like remedies, along with warm-baths and easily-digested food, without any marked change in her condition. From time to time she suffered from severe cardialgia, which yielded to the use of the mag- istery of bismuth (trisnitrate) and belladonna. The emaciation gradually increased, the feet became oedematous, the quantity of brownisli-black urine was reduced, but remained free from al- bumen; the mental powers at the same time became more and more de- pressed. The patient continued in a state of gloomy silence, answered questions either not at all or incompletely, asked for nothing, complained of nothing, and ate the nourishment offered her with a slight appetite. She was generally asleep; on calling loudly to her, she awoke, opened het dull, lustreless eyes, said she felt well, and immediately went to sleep again. Towards the end of October, she had repeated attacks of epistaxis, which were arrested with difficulty. At the end of October, she was suddenly seized with convulsions; the attacks lasted from a quarter to half an hour, and returned from time to time. The somnolence now passed into deep coma, from which she could no longer be roused. The patient now became rapidly collapsed; her skin became shrivelled like that of a mummy, and its temperature sank more and more; the pulse grew smaller, and at last was imperceptible, until death took place on the 23d of Decetn!>er. Unfortunately only a very imperfect post-mortem examination could be made. The liver, stoniacli, duodenum, and pancreas were the only parts carefully examined. The liver was somewhat enlarged, and its right lobe was subdivided by a tiglit-laee fissure. Its surface was smooth; its margins were sharp, except those of the right tight-lace lobe, which were rounded. The gall- bladder ])rojceted 2\ inches beyond the margin of the liver, and contained about oiiuces of turbid ilark-brown bile. The gall ducts, from the duc- tus choledoclius and ductus hepatlcus, as far as their finest terminal ' Finn pressure \i)>on the abdominal walls was made with difficulty, on account of the obstinacy with which the woman kept her muscles in a state of constant contrac- tion. ON DISEASES OF THE LIVEE. 169 branches, contained a quantity of turbid brown, thin fluid, of which from 18 to 20 ounces could be collected on cutting up the organ. The ducts were all considerably enlarged. The hepatic duct measured 1 inch and 4 lines, and was marked by numerous deep pouch-like depressions, leading into the adjoining branches. The parenchyma of the glands was of a dark- brown color, soft and easily compressible; and the outlines of the lobules were indistinct. Upon the cut surface were seen small grayish-white, hard deposits, partly rounded and partly branched, like a tree, which cor- responded with the course of the finer twigs of the hepatic vein, and in some places completely filled these twigs. Crystalline deposits of the same sub- stance lay embedded in the walls of the larger branches of the hepatic veins, so firmly, that on scraping with a knife they could only be separa- ted with difficulty. These crystalline masses were made up of an aggre- gation of fine needles. No abnormal deposits could be detected in the ramifications of the portal vein or of the hepatic artery. The cells of the hepatic parenchyma were in a great measure disintegrated; on microscopic examination only a few were found to remain intact; in their place were seiMi fine brown molecules and oil globules, and also numerous bundles of acicular crystals (tyrosine), and globular masses deposited in concen- tric layers (leucine).' These deposits were at some places densely aggregated, but at other parts were either very scanty or altogether absent. The same crystalline and concretion-like deposits, as were found in the liver, were also present in the turbid bile, along with tables of cholester- ine. A large quantity of leucine and tyrosine was obtained from the sub- stance of the liver, the identity of which was proved by Professor Staed- eler, on elementary analysis.* In the mother-liquid also, from which these bodies had been separated, a substance was observed, which, upon expo- sure to the air, assumed an intense blue color, similar to Chromogen, with which we shall afterwards become acquainted, when considering the trans- formation of the biliary acid into pigment. The liver did not contain any sugar. At the point of entrance of the ductus choledochus into the duodenum, there was a tumor the size of a walnut, with all the characters of villous cancer. By means of this the bile duct was obliterated. The pancreas was flabby and shrivelled; the mucous membrane of the stomach, at some places, was ecchymosed, but without any loss of substance. The spleen was somewhat enlarged and anfemic. Large quantities of the brownish-black urine passed by the patient were examined for the presence of the biliary acids, but always with a neg- ative result. It was not examined for leucine and tyrosine. The morbid process just described is, on the whole, rare; in most of the cases where death has followed as a consequence of occlusion of the bile ducts, the hepatic cells, on post-mortem examination, were infiltrated with coloring-matter, but were otherwise unaltered. The manner in which they become disintegrated is still unknown; this disintegration cannot be attributed with certainty either to the solvent action of the bile, or to the destruction of the branches of the portal vein by the enlarged bile ducts, inasmuch as we often observe the same infiltration of the parenchyma, and enormous enlargement of the ducts, without any such consequences. ' See Miiller's Archiv f. Anat., «&c., 1854. * See Frontispiece, Fig. 4. 170 A CLINICAL TREATISE Whether the derangements of the nervous functions always present the same characters as in the case just communicated must be determined by future experience; this may depend upon the more or less complete disintegration of the hepatic cells, and upon the rapidity with which it takes place. Budd has described a case in which pain in the liver, haema- temesis, headache, and other symptoms made their appearance, but where delirium was only present in the night-time during the last week of life.' c. Acholia from Cirrhosis, Cases have repeatedly occurred to me, in which individuals who for a long period have suffered from cirrhosis of the liver, have suddenly pre- sented a series of morbid symptoms which are foreign to that disease. They have become unconscious, and have been afterwards seized with noisy delirium, from which they passed to deep coma, and in this state have died. In one case there were spasmodic contractions of the muscles of the left side of the face. In most cases, slight jaundice made its ap- pearance at the same time, and in one instance there was petechiae. Upon post-mortem examination, not the slightest lesion could be detected in the brain; neither were there indications of any acute disease which could ac- count for the derangement of the cerebral functions. The liver, in all the cases, presented cirrhotic degeneration in a marked degree, and the glan- dular cells were for the most part loaded with fat; large quantities of leu- cine separated from it; the bile ducts contained only a small quantity of pale bile. Observation No. XX. Ascites. — Anasarca. — Diarrhoea. — Delirium,. — Coma. Cirrhosis of Liver. — Deposits of Leucine in the hepatic veins. — The cen- tral organs of the nervous system normal. E. Radesey, a bookbinder, aged 59, came to the Hospital on the 4th of December, 1854, with great oedema of the feet, and ascites. The heart and lungs were healthy; the hepatic dulness could not be disting'uished; the size of the spleen could not be determined, owing to its situation be- ing abnormal; the veins on the right side of the abdomen were greatly enlarged. The appetite was unimpaired; the stools were thin and pale; the urine scanty, red, and without albumen. The patient confessed that formerly he had been in the habit of drinking much brandy, and could ac- count for his illness in no other way. He was ordered decoction of colo- cynth. Copious thin evacuations diminished the size of the abdomen, and the patient felt himself better. On the ITth, he suddenly fell into a state of unconsciousness, from which lie could not be roused; the countenance became pale and sunk; the pupils were of normal size, and movable; the pulse was 70, and full; stools involuntary; no vomiting. Was ordered in- fusion of Arnica llowers, with spirit of nitric ether. ' Budd draws the conclusion from this observation, that the secreting functions of the liver are not indispensable to the continuance of life, and that a patient may live for a lenirtheiied period after the desLructiou of the hepatic cells; but we are not enti- tled to make such an assumi^tion. ON DISEASES OF THE LIVER. 171 On the 18th, great restlessness; inarticulate cries; complete loss of consciousness; pulse 90; respirations 22. About noon, the mouth was observed to be drawn towards the right, as in paralysis of the facial nerve. On the 19th, pulse 120; deep coma, and stertorous respiration. On the 20th, tracheal rales, and death about noon. Aviopsy. The membranes and substance of the brain were perfectly normal; the lungs, moderately oedematous. Liver small; its outer surface, as well as that seen upon section, covered with cirrhotic nodules, separated by gray areolar tissue; the hepatic cells loaded with oil, and in some places with pigment. Granules of a sulphur-yellow color, and with a diameter meas- uring up to a quarter of a line, were seen upon the inner surface of the hepatic veins. These were firmly adherent to the wall of the vessel, and were densely aggregated, so as to form a pellicle like that of hoar-frost. They were made up of a collection of globular masses of leucine, along with which were observed paler granules and needles, which were insolu- ble in alcohol, but were easily dissolved in ammonia. The gall-bladder contained a small quantity of orange-yellow fluid. The peritoneum and serous covering of the bowels were covered with black specks. The mucous membrane of the stomach and intestine was pale and oedematous, the mesenteric glands were small; the kidneys and urinary passages were normal. Obseevation No. XXI. Ascites. — Diarrhcea. — ITnconsciousness. — Coma. Cirrhosis of the Liver. — Leucine in the Blood and Urine. — Brain normal. Dav. Kliesch, a watchman, aged 53, stated that he had always led a temperate life, and that up to 1855 he had enjoyed good health. In No- vember, he was seized with diarrhoea, which proved obstinate, and was accompanied by ascites, but not by oedema of the feet. The appetite re- mained unimpaired, but the vital powers gradually sank. The heart was normal; pulse 90; slight bronchial catarrh. Hepatic dulness diminished; spleen considerably enlarged. There were from four to six thin stools in the day, containing little bile; urine pale and containing no albumen; skin pale; abdominal veins not distended. Was ordered decoction of cal- umba root with tincture of nux vomica. The appetite continued mod- erate, and the patient's condition underwent little change, except that the ascites increased. On February 4th, he became unconscious: the features were sunk; but the pupils remained unchanged. Pulse 86. On the 5th, complete coma; a faint jaundiced tinge of the skin; sev- eral petechise. Pulse 120. On the 6th, involuntary evacuations; pulse 130; tracheal rales. Death on the morning of the 8th. 172 A CLINICAL TREATISE Avtopsy. The membranes of the brain were moderately congested; the substance of the brain was unaltered; some of the blood-vessels were atheromatous. The lungs were congested and oedematous. In the heart there was a lit- tle loosely coagulated blood, in which could be detected 1.10 per cent, of fat containing cholesterine, and a large quantity of leucine. The lining membrane of the stomach was puffy, and of a livid color. The mucous membrane of the upper portion of the intestine presented the appearance of recent congestion, that of the lower was of a slaty-gray color; in the sig- moid flexure there were a few superficial ulcers, the size of a lentil. The faeces were thin and pale. The spleen was enlarged by one-half; its capsule was thick, and its parenchyma of a uniform dark-brown color. The liver was small; and its capsule opaque and thickened. The outer surface, as well as that seen on section, was covered with little nodules; the organ was tenacious {zOhe), but flabby and shrivelled. The gall-bladder contained a small quan- tity of thin pale bile. The hepatic cells contained a small quantity of oil. The uro-poietic system was normal. The urine obtained from the dead body had a specific gravity of 1011; it was acid, and presented the reaction of bile-pigment in a slight degree. It contained traces of albumen, and along with urea, a moderate quantity of leucine. This last was found in larger quantity in the parenchyma of the liver. D. Acholiafrom Fatty Degeneration of Liver. Only in one case of this form of degeneration have cerebral symptoms been observed. This was a female, in whom the accumulation of fat in the liver became so great, that tlie secretion of the gland was reduced to a minimum. Observation No. XXII. Jaundice of fourteen days' duration. — Somnolence. — Y^omiting. — Sud- den supervention of violent delirium. — Coma. — Death. Fatty degeneration of the Diver in its most advanced form. — Enlarge' ment of the spleen. Louise Fischer, a washerwoman, 44 years of age, was admitted in a jaundiced condition, on the 20th of May, 185G. The jaundice had com- menced 14 days before, and for 8 days the patient had been obliged to keep her bed. During this time, she had been feverish, and had sufi'ered from profuse mucous diarrhcea; the urinary secretion was scanty. Upon examination, we found the temperature elevated, the pulse 128 and small, no abnormal sound of the heart, and the respiratory organs healthy; the abdomen was distended from tympanites; the liver reached as high as the lower margin of the fifth rib, and from this point, in a line with the mam- ma, extended 17 centimetres (G.69 Eng. inches) downwards; the spleen was likewise considerahly enlarged. The stools were frequent, thin, and of a grayish-yellow color: mucous vomiting occurred three times in the course of the day. The urine, which had to be drawn off by catheter, was feebly acid, and assumed a greenish color upon the addition of nitric acid; neitliei- albumen nor the bile acids could be detected in it; but upon further ON DISEASES OF THE LIVEE. 1 73 examination of it, globular masses similar to hypoxanthine, and traces of leucine, were discovered. She was ordered muriatic acid in decoction of mallows. Towards evening, the patient, who, even at the time of her admission, ■was somewhat unconscious, was suddenly seized with violent delirium; she raged and shouted during the whole night; on the following morning collapse set in; the pulse became thready, and the extremities cool. Death took place at 10 a.m. of the 21st. Autopsy, seven hours after death. The membranes of the brain were yellow; the sinuses contained firmly- coagulated blood; the substance of the brain was moderately congested, and of normal consistence. Both lungs were free from adhesions, con- gested, and slightly oedematous, posteriorly and inferiorly. There was a small quantity uf blood in the heart, some of it loosely, and the rest firmly coagulated. The mucous membrane of the stomach and intestines was pale; its glands were not enlarged; there was some thin gray ffecal matter in the ileum and colon; the mucous membrane of the sigmoid flexure was re- cently injected and puffy. The spleen was large; weighed 0.372 kilogr. (13 oz. avoird.): it was soft and of a reddish-brown color. The livep was considerably enlarged; weighed 3.23 kilogr. (71bs. 2 oz. avoird.): its margins were sharp, and its color waxy-yellow. Its cut sur- face appeared remarkably antiemic; the circumference of the lobules was pale-yellow, their centre was greenish-yellow; the hepatic cells in the lat- ter situation were loaded with bile-pigment, whilst in the former, they were distended with oil. The portal vein was unobstructed, and the branches of this vessel, as well as those of the hepatic veins, could be readily filled with colored injection. The gall-bladder contained a small quantitj' of clear, pale, mucous fluid. The bile ducts were normal, and no obstruction could be detected either in them or in Glisson's capsule, oi in the duodenum. The substance of the liver consisted in great part of fat ; it contained 78.07 per cent, of fat, and 21.93 p. c. of areolar tissue; along with the fat, were found large quantities of leucine. In the solid residuum of the blood obtained from the right side of the heart were found 1.91 per cent, of fat, and an amorphous yellow-green coloring-matter, together with traces of leucine. Other forms of disease might be included with those just described, which terminate in a similar manner, by suspension of the functions of the liver. Thus I have had under my care a lady, aged 53, with a very extensive cancer of the liver, as shown by palpation, who was suddenly seized with delirium, convulsions, and coma; whilst at the same time the skin became slightly jaundiced, and covered with petechias. The stools, which at first were pale, and deficient in bile, assumed a brownish-black color, in consequence of hfemorrhage from the bowels. Death took place in the midst of profuse epistaxis. Unfortunately, no post-mortem exam- ination could be made in this case. Acholia must always be expected, when the structure of the liver has undergone such extensive changes from acute or chronic diseases, that the function of the organ is necessarily completely arrested. CHAPTER VI. CHRONIC ATROPHY OF THE LIVER. I. Causes and Mode of Production. The size of the liver in health, is subject to considerable variations, the limits of which we attempted to define in the second chapter. Inde- pendently of this, there are numerous pathological derangements of its nutrition which reduce the size of the gland, and give rise to a corre- sponding diminution of its functional value. These may result from any- thing which permanently impairs or arrests the circulation through the capillary system of the gland.' Hence we observe general or partial wast- ing of the liver in the course of various structural diseases of the organ, as one of the phenomena, and at the same time as a necessary result of the primary disease ; not un frequently, however, the wasting is independ- ent of such a cause. We do not at all refer here to those forms of atro- phy which result from the development of new growths in the liver, such as echinococci or cancerous deposits, or which are dependent upon enlarge- ment of the bile ducts, or upon cirrhotic /vasting and induration; neither do we refer to the partial atrophy produced by the cicatrization of ab- scesses, or by the obliteration of the larger branches of the portal vein, or lastly, to the atrophy of the liver which follows the enlargement of the he- patic veins in mechanical hypertemia: all these forms can be afterwards discussed more in detail under the head of the respective diseases which give rise to them. AYe confine ourselves at present to those forms of atrophy which have an independent existence, are accompanied by no other important change of structure, and hence lay claim to a certain de- ' The liver, like the lungs, possesses a double vascular apparatus, a nutritive and a functional ; the hepatic artery serves the former purpose, the vena porta the latter. Hence impediments to the nutrition of the gland, so far as these are dependent upon the flow of blood, should proceed from the hepatic artery ; this, however, is contrary to experience. A rigid separation of the two functions does not exist in nature ; but not, apparently, because the cnpillariee of the two vascular systems anastomose. Ob- literation of the hepatic artery is not followed by arrest of nutrition (Ledieu, Journ. deMed. de Barde/mx, Mars, 1851) ; G-intiiac, D obliteration de la veiaeporte, Bord. , 1856 ; p. 51). Occlusion of the portal vein is not followed by a cessation of the secretion of the liver (GiXTii.\c ; aho my own (■bsercati-nns, Nos. XXIX. and XXX). So far as our present experience extends, the portal vein exercises a more powerful influence over the preservation of the normal volume of the liver than the hejiatic artery, which, for the most part, supplies only the walls of the bile ducts and blood-vessels, and pene- trates but a short distance into the interior of- the lobules. Diseases of the hepatic artei-y and its brandies, of such a nature as to obstruct the flow of blood, are but little known, and, indeed, have been but little sought for. 1 have myself frequently ob- ser\'ed only one alteration in these vessels as of frequent occurrence, viz., an accumu- lation of black pigment. We have no experience as to the influence of functional de- rangements of the hepatic plexus of nerves, over the nutrition of the parenchyma of the liver. ON DISEASES OF THE LIVER. 175 gree of individuality. This form of atrophy makes its appearance under very various conditions. The first cause which we recognize is the compression of the organ from without, from which results an amount of atrophy corresponding to the extent and force of the pressure. Bearing upon this there are the familiar effects of tight-lace chest, already mentioned under the head of " Diagnosis." Besides the alteration in the situation of the liver, tight- lacing produces more or less deep depressions on its surface ; and the glan- dular parenchyma at the parts corresponding to these depressions dwindles into a mere bridge-like process penetrated by the enlarged vessels and bile ducts; at the same time, the organ in many cases becomes shrivelled and collapsed. The loss of substance which the gland undergoes from this cause is, as a general rule, but very slight ; it is a removal ( Verdrdngung) of the parenchyma, which takes place, rather than an atrophy. Occasionally the liver suffers more from compression of its convex sur- face by extensive pleuritic or pericardial effusions, especially when the gland is firmly united to the diaphragm by short adhesions. Under such circumstances, extensive depressions are not unfrequently produced on the surface of the gland; the parenchyma at the places corresponding to these depressions assumes a dark-brown color; the cells become smaller and lose their granular contents; whilst at the same time a few brown granules make their appearance in their interior. (Fig. 24.) fr^^\ FlQ. 24. Fig. 24 — Secreting cells of a liver, whioh had undergone chronic atrophy. The cells were much reduced in s=ize, measuring only from ^^^ to j\-- of a Paris line. They have also lost their normal granular contents. FiQ. 2,5 — Chronic atrophy of the liver, resulting from the external compression of peritoneal exudations, circumscribed between the concave surface of the diaphragm and the upper surface of the gland. A similar result is produced by circumscribed peritoneal exudations, which occasionally leave behind deep depressions on the convex surface of the liver. (Fig. 25.) Cruveilhier ' observed a considerable depression resulting from the compression of an hypertrophied heart, the gland being at the same time firmly adherent to the diaphragm. Similar consequences may arise from enlargement of those portions of the intestine which are nearest to the liver, if, from their being dis- tended with gas or fa3cal matter, they exert a permanent pressure upon the organ. In this way, I have seen an extensive diminution of the liver produced by an enormous enlargement of the curve of the colon. The case was that of a man, aged 36, in whom a circumscribed peritoneal exu- ' Anat. pathol. gener., Tom. III., p. 208. 176 A CLITNTICAL TREATISE dation had formed in consequence of a chronic perforating' ulcer of the stomach. This gave rise to a constriction of the left curve of the colon, and to a stagnation of the gaseous and solid contents of the transverse and ascending colon. By this enlargement of the bowel the liver was pushed towards the ribs, high up into the right hollow of the diaphragm; the left lobe, which was situated nearest to the compressing cause, as also a portion of the right lobe, were atrophied. Budd ' describes a par- tial atrophy of the gland in a preparation preserved in the Museum of King's College, which was obtained from a patient laboring under para- plegia, in whom the large intestines had for a long period been dis- tended. Cruveilhier is of opinion, that a diminution of the parenchyma of the liver is produced by the pressure of the fluid of ascites, as also by the adhesions of the organ to neighboring parts. I have not been able to convince myself of this, even in cases where there has been the most ex- tensive ascites and the most numerous adhesions. I have not unfre- quently found the organ small, but often of normal size, or even enlarged. In chronic peritonitis, it is only when the liver has for a long time been covered with a quantity of purulent exudation, or when the inflammation has extended to the fissure of the liver and Glisson's capsule, that a dimi- nution of the organ has been observed to be of constant occurrence. The atrophy which arises in the way just described, as a general rule, remains partial; its clinical importance is usually small, and depends upon the extent of the atrophy, and upon whether or not the larger bile ducts and blood-vessels have been subjected to the pressure. The diminution of the liver, which extends throughout the entire organ, is of much more importance than this atrophy from compression, both as regards its consequences upon the entire organism and its local effects on the portal system. The liver here diminishes in every direc- tion; its weight sinks to one-half the normal weight, or even to less.^ The surface of the gland is smooth or slightly granular, or marked by linear wrinkles, and in some cases presents likewise distinct, isolated de- pressions; the parenchyma is dark reddish-brown, and is sometimes spotted with greenish-brown or 3'eLlow deposits of fat. In most cases, no trace of the lobules can be distiTiguished in the uniformly brown surface; when they are observed, tlioy appear smaller than in the healthy gland. ^ Important alterations may be distinguished in the blood-vessels; the portal vein is usually considerably enlarged as far as its subdivision into capillaries at the periphery of the lobules, at which place the enlargement tei'minates by a club-shaped extremity. The walls of the. enlarged veins are sometimes normal, but at other times they present a remarkable thick- ening of the sheath, formed by Glisson's capsule.* This thickening dis- appears suddenly Avhere the capillary ramifications commence. The capillaries themselves are in a great measure destroyed; they become filled with brown molecules, or they sometimes contain flakes or granules of ' " On Diseases of Liver." ^ In one female, aged 20, the weight was 0.7 kilogr. (1 lb. 8^ oz. avoird.) ; in a man, 53 years of age. it was 0.85 kilog. (1 lb. 14 oz. avoird.); in a women of 50, it was 0. 80 kilogr. (1 lb. li^ oz. av.) ; and in a man aged 59, it was 0.62 kg. (1 lb. 6 oz. avoird.). ■* The thickness of the parenchyma between a central and an inter-lobular vein measures from a i to | of a millimetre ; whilst in other cases this space is 1, 1^, or 3 millimetres in breadth. ■* In G out of 18 cases. ON DISEASES OF THE LIVER. 1 77 black pigment; hence injections of the portal vein usually succeed 'very imperfectly; it is only here and there that a few isolated capillaries become filled as far as their anastomosis with the roots of the hepatic veins; the latter are usually more easily injected, and the injection runs to a greater distance. The meshes formed by the capillary vessels and by the envel- oping areolar tissue are contracted, and at some places completely disap- pear, so that the walls of the obsolete vessels are in immediate contact with one another. Small atrophied cells are here and there observed in the narrow meshes. The hepatic veins in many cases participate in the enlargement of the vena porta, but always in a less degree; their walls for the most part con- tinue thin, and hence their bluish color forms a marked contrast with the yellowish-red of the walls of the portal vein. The hepatic artery in two cases has appeared somewhat smaller than natural; Glisson's capsule has frequently been found thickened. The hepatic cells, which at some parts of the organ completely disappear, are distinctly visible at other parts, but are always pale, without any granular contents, with puckered walls and angular outlines; for the most part they are very small; they often con- tain brown pigment granules, which occasionally fill up completely the cavities of the cells, or little rods of the brown coloring-matter of bile. In many cases' cells are found filled with oil, sometimes scattered throughout the entire organ, at other times in isolated deposits. In the bile ducts there is only a small quantity of a pale secretion, which frequently con- tains albumen. Together with these changes in the liver, I have frequently observed enlargements of the veins of the stomach and large intestine, as also sub- serous ecchymoses and mechanical congestions of the spleen. This last was present in seven out of eighteen cases. Ulcerative processes in the stom- ach and intestine were present in 8 cases, 3 of which were caused by chronic dysentery; 2, by simple chronic ulcer of the stomach; and 3, by cancerous ulceration; in one case cord-like thickenings in the mesentery, with obliteration of isolated venous branches, could be detected. As consecutive changes, ascites and anasarca were found twelve times, and acute peritonitis twice. Observation No. XXIII. Chronic Atrophy of the Liver, xoith conslderahle enlargement of the branches of the portal vein. — A small ulcer at the pylorus, xoithout any constriction of this opening. — Distinctly visible, peristaltic movements of the Stomach. — Death from exhaustion. Adam Blaschefsky, a day-laborer, aged 53, was admitted on the 21st of November, 1854. The patient was emaciated, but free from any oedema and from any abnormal coloring of the skin; he had complained for a long time of pains in the epigastrium, and had often brought up the food which he swal]ass through them with dilHculty, unless it is in a state of very line division. When olive oil is injected into the roots of the portal vein, it is retained in the vessels of the liver, and does not reach the right side of the heart. Under such circumstances, there are found in the liver round cysts the size of a linseed, whicli are filled wifcli oil. and which are for the most part associated in groups of from three to seven ; some of the branches of the portal vein are filled with pure oil ; other.? contain blood as well, and occasionally, also firm coagula. If the animals remain alive for several days after the injection, there may be observed scattered through the brown substance of the liver yellow masses containing but little blood, and in wliich the secreting cells are lilled with large and small drops of oil. In one case, in which the anim;il d d not die until after three weeks, the liver was col- ored yellow to a 'jfreat exte)it, and jienetrated by a beautiful dark red network of ves- sels. The hepatic cells were distended with oil globules. a)id in some places they ap- peared to l)e crumbling down into a fatty del'ris. Besides the more prominent yellow portions, there wa.^; the nonnid reddish-brown hepatic tissue, containing cells free from oil. In one case, signs of slight jaundice made their appearance after the injection. OIT DISEASES OF THE LIVER. 199 How this is effected is still uncertain. It is probable, that when the accu- mulation of fat is considerable, one portion returns as such to the blood, whilst another is made use of in the formation of bile. It has been often justly observed, that from the chemical properties of the biliary acids, it is probable that fatty matters take part in their original formation. Tho histological characters of the liver support such a supposition in so far as the quantity of fat diminishes simultaneously with the appearance of yel- low matter in the hepatic cells; it is only in exceptional cases that we observe both together.' It can scarcely, however, be doubted, that there are other modes in which the fat is disposed of. The deposit of fat in the liver of the lower animals, and especially in that of fishes, is so abundant, that it cannot be imagined that the substance is entirely consumed in the secretion of bile. In these cases, the gland appears to serve as a depot for fat which afterwards returns as such into the circulation, and is then subservient to some purpose. In support of this view it is worthy of notice, that even fishes which are destitute of fat in other parts, possess a liver, which is unusually rich in this substance, and farther, that according to Leydig, in Paludina vivipara, before the commencement of its winter sleep, the liver is rich in fat, and assumes a white hue, whilst at other times it is brown. It is not merely food unusually rich in fat that gives rise to these de- posits in the liver, but, under certain circumstances, every kind of food, when in too great quantity, has the same effect, even when it is free from fat, and only contains a large quantity of the carbo-hydrogens. Here, however, the deposit does not make its appearance in the liver until the other organs and tissues, such as the cellular tissue, are loaded with fat, nor until the serum of the blood begins to be milky. Lereboullet ' ob- served, that on feeding geese with maize, the relative weight of the liver in proportion to that of the entire body was at the commencement reduced; whilst the cellular tissue first became loaded with fat; not until some time afterwards did the liver increase disproportionately and become infiltrated with fatty matter; at the same time, the secretion of bile diminished, and the serum of the blood became turbid. In this case, the fat was not con- veyed directly to the liver, and its deposit in this organ did not commence until the composition of the blood, and the nutrition were essentially modified in consequence of an improper diet.* From what has just been stated, it will be understood how a fatty liver is not unfrequently found in individuals who have died suddenly in Similar changes could not be brouglit about by injecting the jugular veins with oil. It cannot be determined whether the fat, upon digestion, is carried directly through the portal vein to the liver ; the blood of the portal vein, after feeding on fat, undergoes no change, which would warrant us to answtr this question in the affirma- tive. ' Lereboullet even observes {op. cit., p. 86) : — " Les cellules graisseiises ne me para- issent ctre que transitoires ; je crois qu'elles se transforment elles-mcmes en cellultg blliares pars depot de granules biliares et par disparition de la graisse, qu'elles renfer- maienfc." = Op. cit. , p. 96. 'Claude Bernard {Leconfi de pJiys. eo'jih-im.^ 1855. j). 149'i is of opinion that the sugar wliich passes from the digestive organs to the liver, is here converted into fat. The milky matter found in a decoction of the liver, and upon the appearance of which, after the use of a diet containing sugar. Bernard mainly relied in making this state- ment, is poor in fat, and is, moreover, found also iu animals which have been re- stricted for a long time to animal food, and occasionally also in the foetal liver. 200 A CLINICAL TREATISE the bloom of good health.' It is then merely a transitory phenomenon, and does not of itself constitute any disease. By a persistence, however, in improper food, the deposit increases more and more, and gradually ex- ceeds the boundaries of health. In such cases there are usually other agencies at work, which aggravate the bad effects of diet. First amongst these, is a diminished activity of the metamorphosis of matter, such as is found in individuals who avoid all bodily and mental exertions; secondly, there is a defective action of the liver, from which results an incomplete application to the formation of bile of the fat brought to this organ; and lastly, there are constitutional influences of an unknown nature. There are some individuals in whom the metamorphosis appears to take place slower than in others; in such persons there is wont to be a predominant tendency to the deposit of fat in the various organs and tissues, whilst the secretion of bile, so far as this can be ascertained, is scanty. This is the case even in animals; and in the experiments of feeding above described, differences were observed in respect to the rapidity with which fat was deposited in the secreting cells, which were of a purely individual nature. These discrepancies apparently depended upon dissimilarities in the development and functional activity of the several organs, which are concerned in the absorption and metamorphosis of the elements of food. Such constitutional peculiarities are hereditary; and this partly explains why it is that a train of abdominal derangements, haemorrhoids, excessive embonpoint, &c., are herditary in certain families, and how successive generations come to be visitors at Kissingen, Marien- bad and Karlsbad. P]ven as regards the mere digestion of fat, important dilterences exist. There are individuals wlio can only tolerate very small quantities of fat, without tlie functions of the stomach becoming de- rang'ed, whilst there are others who consume a large amount without any ill effects, and still continue lean; and again, there are others in whom the use of large quantities of fat is followed by a corresponding increase in bulk. Along with individual idiosyncrasies there are agencies of a more gen- eral nature which favor the deposit of fat, and with the mode of opera- tion of which we are as yet only partially acquainted; such are, the middle period of life, the female sex, and a temperate, humid, marshy climate.'^ The modes of origin of fatty liver hitherto discussed may, for the most part, be reduced to external agencies; in other cases, this condition exists in connection with internal patholog'ical processes, some of which at least do not at all directly implicate the liver. Of these morbid processes we are particularly familiar with the frequent concurrence of fatty liver with pulmonary tubercle, and other wasting diseases, as also with the drunkard's dyscrasia; both of these morbid conditions, however different they may be in other respects, agree in this, that the blood is usually characterized by the presence of a large quantity of fat, and that a milky turbid serum separates from it. This, indeed, is the cause of the change which the hepatic tissue undergoes in these affections. The production of fatty liver in the course of pulmonary tubercle has been attempted ' I have found the liver very fatty in a railroad official who was killed at his em- ployment ; also in a mason who met with his death from a violent fall ; and likewise repeatedly in iiidividuals who have died after a few days' illness, during the eruptive gia^e of the acute exanthemata, scarlet fever, and measles. ■^ See Prout : On Stomach and Renal Diseases, 5th Ed. , p. 255. ON DISEASES OF TKE LIVER. 201 to be explained in various ways; most writers lean to the view which attributes the production of the carbo-hydrogens and fat to obstructed respiration, and to the defective oxydation of the blood, resulting from this. Without entirely denying the influence of respiration, — as has often been done, on the ground that in other derangements of the respi- ratory functions, such as emphysema, fatty liver docs not make its ap- pearance, and that it is met with in cases where there is tubercular de- posit in other parts of the body, such as the bones [RoJcitansky), — I be- lieve myself, that the cause of this form of fatty liver must be sought for in those changes in the composition of the blood, which take place during the process of wasting. The blood becomes loaded with fat, which is taken up during the advancing emaciation, in order to be employed for supplying the demands of the metamorphosis of matter in the sys- tem.' The accumulation of fat in the liver is usually more remarkable in pulmonary tubercle than in other wasting diseases, in which the respi- ration is unaffected, merely because the impaired absorption of oxygen entails a more tedious metamorphosis. In women, in whom the adipose tissue is wont to be more developed than in men, the absorption of fat is greater; fatty liver is, therefore, more common, and more marked in tubercular females than in males. The condition of the digestive system exercises a farther influence; the more this is impaired, and the more the secretion of bile becomes from this cause diminished, so much the less of the fat which has been removed from the body is employed in the formation of bile, and so much the more of it accumulates in the liver. In other wasting diseases, fatty liver occurs certainly less frequently than in pulmonary tubercle, but still oftener than is usually believed. Bright mentions cases in which it appeared in the course of chronic dysen- tery and along with cancer; Budd records other instances of fatty liver accompanying cancerous ulcers, and I have myself observed the most ad- vanced grade of the disease going along with compression of the spinal cord, in a case where great exhaustion was induced by a sloughing bed- sore. (For further examples, see the Table showing the different diseases in which this affection is met with.) Accumulation in the blood of fat proceeding from another source, is the cause of the fatty liver of drunkards. To what extent the direct influ- ence exerted upon the liver by the alcohol entering the blood can contrib- ute to the development of the affection in question will have to be dis- cussed in the chapter on cirrhosis. From what has already been stated, the general conclusion may be drawn, that in every instance in which the blood becomes loaded with fat, either as a consequence of improper diet, or owing to abnormal conditions of the metamorphosis of matter, infiltration of the liver with fat may be developed, either in a transient or permanent form. There are two sets of glands, particularly, which become implicated by this altered composi- tion of the blood, viz., the liver and the sebaceous glands of the skin. A greasy, or velvety character of the cutis is thus a frequent accompani- ment of fatty liver, and may, under certain circumstances, be of service in diagnosis. ' This view was expressed years ago by Larrey, who appealed to the injurious method then prevalent in France, of promoting the formation of a fatty liver in geese. The animals were shut up in close, hot cages, without food of any sort whatever, whereupon they became ill and remarkably emaciated, whilst the liver became enlarged and fatty. 202 A CLINICAL TREATISE Besides these general influences which act through the medium of the blood, there are other derangements of a local nature, confined to the liver itself, which may tend to fatty degeneration. That such agencies really exist, is shown by the partial development of this affection in isolated masses scattered through the liver, while the remaining portions are com- paratively sound. Limited local deposits of this nature are found in atro- phied livers and in cirrhosis, where not unfrequently a portion of the lob- ules, or even the half of an individual lobule, is in a state of fatty degen- eration, while the remaining portion or half remains exempt; they are fur- ther found in lardaceous {speckig) infiltration of the liver, and lastly, in the circumference of cancerous nodules, cicatrices, and inflammatory de- posits, &c. Moreover, pale, irregular spots, -^ to 2 inches in diameter, are not unfrequently observed over the outer surface of the gland, which in other respects is normal; these penetrate several lines into the sub- stance of the parenchyma, and then terminate by a defined border. Such places sometimes contain pale, perfectly normal, hepatic cells, but fre- qui;ntly also cells filled with fat. The causes which occasion such local changes can only be partially investigated with any degree of certainty. In most of the cases, the fundamental causes are abnormal conditions of nutrition, such as are perceived in consequence of hypera?mias arising from an alteration in the character of the fluid pervading the tissues, which are often found in the kidneys, the pulmonary epithelium, the muscles, &c. In tliis way we must explain the fatty degeneration of the hepatic cells, Avhich takes place in the neighborhood of inflammatory deposits, cicatrices, and pathological new-growths, and, to some extent, also in cirrhosis, A similar explanation may be given of the formation of fat throughout the entire organ in the cells undergoing disintegration in acute atrophy, and also of the fatty degeneration, which occasionally takes place in the later stages of the so-called lardaceous or waxy infiltration [der specJcigen Infil- tration). The deposit of fat in the liver which originates in this way, is essen- tially different in its consequences from the first-described form. In that, the fat was simply deposited in the cells, which were not altei-ed in their other characters; but, on the otlier hand, in the instances last enumerated, the cells which are infiltrated with an abnormally concentrated plasma, and of which the nutrition is partially impaired, cease entirely to perform their functions. We distinguish this form of fatty degeneration from the former, which we may designate fatty infiltration. In many cases, how- ever, where the deposit of fat is partial, its mode of origin cannot be traced in the manner just mentioned; the same remark is applicable to the deposits of fat, which one often finds in atrophied livers, where some of the cells are collapsed and shrivelled, whilst others are filled with fat, and to the deposits which are found scattered through comparatively sound livers, &c. In such instances deranged nutrition may be at one time to bliime, and at another time an impaired condition of the secreting func- tion; and it is not impossible that other influences of an unknown nature may also operate. II. — Structural characters of Fatty Liver. So far as my experience extends, the dej^osit of fat in the liver is al ways limited to the secreting cells; I have never been able to discover de- posits of fat in the intercellular spaces of the parenchyma even in the most ON DISEASES OF THE LIVER. 203 advanced stages of the affection.' Appearances are not unfrequently in favor of a deposition in the intercellular spaces, inasmuch as in preparing objects for microscopic examination a number of cells become destroyed, and their fatty contents escape, and thus appear to lie external to the cells. Where, however, the elementary structures are isolated with care, we find the fat everywhere enclosed in cells; these cells are sometimes distended to such a degree that their external membrane only becomes visible after the removal of the fat by the addition of oil of turpentine. In fine sec- tions of the liver made after the organ has been injected and dried, Ave can see the cells loaded with fat, in the spaces corresponding to the meshes of the blood-vessels: these cells can be freed from their contents by treatment with ether. By boiling the sections with ether, we easily succeed in remov- ing the cells; and then the vessels with their sheaths of areolar tissue alone remain. It is our convic- tion, that an interlobular fatty liver does not exist, and indeed it would be difficult to reconcile the ex- w n istence of such a lesion with the anatomical distribu- loadea witii oil giouuies, ia tion of the elementary tissues of the hepatic paren- Si^"iicUy\^iMbie ""''^'''^ '* chyma. The fat is at first deposited in the form of fine small drops in the in- terior of the cells, usually close to the nucleus, but also at other parts of the cavity of the cell. These little drops then increase in number and size, they approach nearer to one another, the granular and brown mole- cular contents diminish, and the nucleus is obscured. In most cases, the nucleus comes into view on removal of the fat by means of oil of turpentine; it does not usually disappear until the accumulation of fat has become far advanced, and not always even then." The little drops of oil afterwards run together, into two, three, or four large drops; and these also, in the further progress of the disease, often become united into one single drop, almost entirely filling up the cavity of the cell. The granular cell contents, with the small oil globules, are then seen to be pressed to one side, and to surround the margin of the large drop of oil like a fringe. The fat itself in general appears fluid; we rarely see solid granules or drusic masses of crystalline needles of margarine, such as were figured by J, Vogel and Lerebouilet. The accumulation of fat usually causes the cells to enlarge; in cases where the deposit is partial, the cells containing oil have a larger diame- ter than other cells from the same liver which contain none; this, however, is by no means always the case. Very small cells containing fat are some- times found, particularly in atrophy of the liver, and frequently even when the accumulation of fat is considerable, we are unable to detect changes of anv sort in the size of the cells.' ' J. Vogel {Icon. HiHol., Taf. XIX. and XX.), and, more recently. Wedl {Grundzuge der pathol. Hixtoiog. Wien, 1854. S. 193 ; trdiid. by the St/d. ^/c. 1855, p. 162), main- tain that they liave observed such a deposition of fat. The latter distinguishes two forms of fatty liver ; in the one. which he calls the lobular fatty liver, the oil globules lie scattered everywhere through the dirty -j-ellow substance of the liver; in the second form, or the interlobular, they lie in the interstices of the lobules. ^ LerebouDct believes he has ascertained that the nucleus perishes when the de- posit of fat reaches an advanced stage. JMy own experience is at variance with this. Many cells, containing a large quantity of fat, possess a distinct nucleus. (Fig. 29.) 3 The cells of a fatty Kver measured 0.030 to 0.025 or 0.022 of a line ; those of a 204 A CLIIsICAL TREATISE In most cases, when the disease is in an advanced stage, tlio form of the cells becomes altered; their angular outlines disappear, and their form becomes more rounded; when the accumulation of oily matter is consider- able, the outer surface of the cell assumes an uneven character from the projecting oil globules. The wall of the cell cannot then always be detected; it does not become distinct until the fat has been removed by means of ether or oil of turpentine; previous to this, it is often impossible to distinguish the cells v/iih their contents from aggregations of globules of oil. In proportion to the increase of the fatty matter, the remaining contents of the cells recede; the fine granular contents diminish, as also the albuminous substance, which is rendered turbid by alcohol, and espe- FifT. 30. — Re|ireseiits a niiisnifieil thin section of a fatty liver in a moderate degree of advancement. The cells ciiniainin;:: oil are set-n to lie disiribured. lor the mont part, at the jicriphery of the lobules, in the vicin- ity of the branrhes of the iiortiil vein (jinle). As the disease n''vHiiecs. ihey jienetrate farther into the tiiib- stanee of the lobnles tnwurds the eentnil veins (dark). A ii-ansvirse section of one lobule shows that it contains two central veins. Tlie cells containing pit;;nent !\vc s:tn:ited mostly towards the ceutre of the lob- ules, as seen at upper part of cue. Copied from Atlas, Plate VI., I".g. 2. cially the brown or yellow granules and globules, which are the product of the secreting function. No trace of these substances is usually to be found in tiie cells which are loaded with fat, whilst they are accumulated in considerable quantity in those which contain no fat. It is only in ex- cej)tional cases that we find fat and pigmentary substances associated. healthy livor, taken from an individaal of tlie same age, measured 0.030 to 0.022, and anotln^r. 0.01.") to 0.017 of a line. These numbers iudicate a considerable iucrea.se of size in tlie Litty cells. ON DISEASES OF THE LIVER. 205 This usually only occurs to any extent, when the deposit of fat has affect- ed all the cells, as far as the centre of the lobules. The alteration which has just been described in the hepatic cells almost always commences at the periphery of the lobules, in the region of the in- terlobular vessels pertaining to the portal vein,' and advances step by step towards the centre of the lobules, which is supplied by the hepatic veins. (Fig. 30). We can distinguish three stages in the development of fatty liver. In the first stage, the cells in the neighborhood of the ramifications of the portal vein become fatty, and this abnormal appearance gradually disappears towards their centre, the cells being here partly normal in their characters, but for the most part loaded with pigment. In the second stage, the deposit of fat advances more than half-way to the centre of the lobules, and it is only in the immediate neighborhood of the central veins that we can detect cells still containing pigment and free from oil. In the third stage, the change extends as far as the central vein.* Some authors, and particularly Wedl, speak of a softening of the fatty liver: a condition in which free fat, molecular masses, and nuclei, are all that remain visible of the hepatic cells, the walls of which must, therefore, have become destroyed. Without wishing to call in question the possibil- ity of such a destruction of the secreting cells, I must observe, that I have never met with this appearance myself in simple fatty liver; on carefully treating the tissue with oil of turpentine, I have invariably detected the walls of the cells still intact. Such a destruction I have only observed at places, where new areolar tissue has been developed in the parenchyma of the liver, in consequence of exudation processes. In such places we see infiltrated here and there, through the elementary structure of the new tissue, rounded groups of oil globules, and of brown granules, which are the debris of former cells. Here, however, and in all cases where ex- udation-processes constitute the causes of fatty degeneration, the mode of deposition of fat in the cells, as well as the other characters of these cells, is entirely different from what we find in the ordinary fatty liver of persons laboring under tubercle, and in that of drunkards. In the latter cases, the fat is deposited in the interior of the cells directly from the blood; in the former, the tissue first becomes infiltrated with abnormally concentrated plasma, in consequence of which the endosmotic properties of the cells are altered, and their nutrition is impaired. Under such cir- cumstances the cells are seen in the first place to become filled with a granular albuminous precipitate, obscuring the nucleus, which only becomes visible on the addition of acetic acid; it is not until afterwards that oil globules make their appearance in large number, but even then they are seldom remarkable for their size. This fatty degeneration of the liver, which we believe to differ from fatty infiltration, is usually limited in its ' Exceptions to this are rare ; in a few cases only I have observed the reverse hold good, the cells at the circumference, next to the portal vein, being free from fat, and those in the neighborhood of the hepatic veins, infiltrated. In one of these cases there existed a passive congestion of the blood in the roots of the hepatic vein, in consequence of mitral incompetence ; another case was an example of hypertrophied fatty liver. ■■' If we wish to obtain a distinct view of this distribution of the fat, we must inject differently-colored substances into the portal and hepatic veins, and then cut up the liver into small pieces, and carefullv dry it ; fine sections of this, made with a razor, may then be examined under the microscope, either at once, or better, after the fat bns been removed by boiling with ether. In the latter case, the fatty cells are re- moved, and the areolar tissue, containing the blood-vessels, only remains. 206 A CLINICAL TREATISE extent to the circumference of inflammatory deposits, recent exudstjons, cicatrices, &c. ; it is found extending over the entire organ, apparently as a terminal stage of infiltration of colloid matter, in the so-called larda- ceous or waxy liver (Speckleber). We have repeatedly met with in- dividuals presenting lardaceous spleen, and in some cases also, lardaceous liver, in whom the liver, which at first had been large and tense, became in the course of treatment smaller, softer, and more shrivelled (welker). The hepatic cells were found filled with oil globules and granules, but con- tained no substance yielding, with iodine and sulphuric acid, the charac- teristic reaction of colloid matter, which, however, could be detected in the spleen and kidneys. This degeneration is far more injurious to the functions of the orgAn than infiltration.* m. — Qtiantity of Fat. The quantity of fat which is deposited in an advanced stage of fa^f.y liver may be considerable. In one case I found 78.07 per cent, of fat in the substance of the liver after this had been freed of its water; — the quantity of fat, therefore, amounted to nearly four times that of the re- maining portions of the tissue; — in its fresh state, this same liver contained 43.84 per cent, of fat, 43.84 of water, and 12.32 of areolar tissue, cells, and blood-vessels. In another case, the quantity of fat amounted to 76.6 per cent. The quantity of water contained in the hepatic tissue is considera- bly diminished; it falls from 78 per cent, to 50 or even to 43.84. Along with the fat, which consists of oleine and margarine in varying proportions, with traces of cholesterine, sugar has been found in most cases. Where the deposit of fat has attained an advanced stage, we have also succeeded in finding large quantities of leucine and tyrosine. In some cases, moreover, there is a peculiar yolk-yellow substance, which differs essentially in its characters from bile-pigment. It is worthy of notice, that the decoction of the liver is always found poorer in free acid than in the normal state. Cystine has been sought for, but in vain. IT. — The General Anatomy of Fatty Liver, It is not always possible to arrive at a positive opinion as regards the fatty contents of the liver, by means of simple inspection. Moderate, or even advanced degrees of this abnormal condition do not always alter the color and consistence of the organ in such a manner, that they can be distinguished with certaintv from other changes in the gland, and espe- cially from anremia; there is a pale and soft liver, which in its characters so closely resembles the fatty liver, that it is liable to be mistaken for it, and yet which contains no fat. A perfectly certain decision in this matter can only be arrived at by means of the microscope. I do not regard the coating on the blade of the knife which remains after making a section of the organ, and upon which anatomists lay great stress, as a criterion to be relied upon, because this coating is also observed in the case of soft livers containing biit little fat, when the cells are only loosened in their adhesions to one another, and contain a quantity of granular matter. ' See Oba. XXXL p. 217. ON DISEASES OF THE LIVER. 207 It is true, that forms of fatty liver are met with, which with some ex- perience can be immediately recognized as such; such, for example, as the large flattened, dull-yellow liver, with rounded margins, and a smooth,' tense peritoneal covering, which on section is found to contain but little blood, and to present a color similar to that of autumn foliage {liokitansky). These characters, however, cannot coiistitute a rule for our guidance, in- asmuch as there are so many exceptions to them. The size and weight of fatty liver are liable to great variations; they may exceed, correspond to, or be less than, the normal size and weight. When the results of numerous weights and measurements are taken to- gether, the weight and volume are on the whole increased. Out of 34 cases of fatty liver in adults, the average weight was found to be 1.6 kilogr. (3 lbs. 8^ oz. avoird.) in males, and 1.5 kilogr. (3 lbs. 5 oz.) in females.' The ratio of the weight of the liver to that of the entire body was as 1 to 28 in males, and as 1 to 25 in females.' The average measurements were as follows: — In males, right lobe 5,3 inches; left lobe 3.4 in. transversely. " « 7.7 " ; " 5.6 " longitudinally. Thickness, 2.1 inches. In females, right lobe 5.8 inches; left lobe 3.3 in. transversely. " " Q.Q " ; " 5.6 " longitudinally. Thickness, 2.3 inches (Paris inches). The weight of the spleen in these cases amounted in men to 0.23 kilogr. (8.1129 oz. avoird.); and in women to 0.24 (8.465 oz. avoird.); and the relative weight of the organ to that of the entire body was as 1 to 202, and as 1 to 156. The relative weight of the spleen to that of the liver, was as 1 to 6.90 in males, and as 1 to 6.25 in females. Besides the hypertrophied fatty livers, we often meet with others, which are atrophied, their size and weight being less than that of the nor- mal state, although the amount of fat which they contain is considerable. Such atrophied forms are by no means rare. The form of fatty liver is in many cases peculiar; the organ increases mainly in breadth, is flattened out, diminisiies in thickness,^ and has its margins rounded. But to these characters there are also numerous excep- tions; even when the deposit of fat is considerable, the margins of the or- ' The outer surface occasionally appears to be slij^litly granular, from the periph- eral portions of the lobules which contain fat becoininsif more prominent than the cen- tral portions. For the relation of this form to granular liver, see chapter on " C'ir- rhosis." - Cases, however, have been met with in which fatty liver has attained a great weight ; thus, in a female aged 40, it was found to weigh 3.4 kilogr. (7 lbs. 8 oz. av.), and its relative weight to that of the whole body was as 1 to 20. ^ LerebouUet has attempted to determine the changes in the relative weight of the liver to that of the entire body which the organ undergoes in geese, from being made fatty. Before the commencement of the feeding on maize, it was as 1 to 26.5 ; after nine days' feeding, it was as 1 to oO ; after fourteen days, as 1 to 18 ; and after twenty- eight days, as 1 to 13.8. Thus the consequences of excessive feeding manifest them- selves during the first nine days, in an increase of the weight of the body; but after this the increase of weight is mainly in the liver. * This is shown by the mean measurements above given. 208 A CLINICAL TREATISE gan may be sharp, and its measurements in every direction may remain normal. The color in general becomes paler, and the more so, in proportion to the abundance of fat, and the extent to which the normal contents of the hepatic cells and the capillary injection are reduced. A considerable amount of fatty deposit may take place without the color being essentially changed. In most cases, the parenchyma of the liver assumes a reticu- lated appearance; we find a reddish-brown and a pale-yellow substance alternating with one another; the latter usually forms rings surrounding little rounded islets of the former substance; or the brownish substance presents longitudinal or sometimes leaf -like figures, bounded by a pale margin.^ Which of these appearances presents itself depends upon the direction in which the lobules are divided, the latter occurring when the section falls parallel to the branches of the hepatic veins, but the former, when the central veins are divided transversely. The pale parts almost always correspond to the periphery of the lobules, the region of the por- tal vein, in which the fat is usually first deposited, while the dark parts correspond to the hepatic veins around which the cells are wont to con- tinue rich in pigment, and the capillaries, filled with blood." The area on section of the individual lobules is enlarged. In the most advanced stages of fatty deposit the liver is pale-yellow, and only small intensely-yellow dots or streaks stand out of a uniformly-colored ground; these are the pigment cells in the neighborhood of the central veins. In such cases the finer vessels on the surface of the organ are completely deprived of their blood; but ramifications of enlarged vessels are seen in the serous cover- ing, the same as in cirrhosis. Sometimes v.'e see large yellow islets scattered through the parenchyma, corresponding to places where there has been a particularly great obstruction to the bile. When the deposit of fat does not take place in a uniform manner, it mav assume the form of streaks more than an inch in length, or of pale in- sular masses of a greater or less size, occasionally not exceeding in diam- eter that of a bean or pea. These patches are more frequently observed upon the surface (from which they penetrate only a few lines into the pa- renchyma), than deep in tlie interior of the organ. The consistence of the liver is wont to diminish in proportion to the increase in the deposit of fat; it becomes Habby, abnormally soft and eas- ily broken up, and, like ^edematous areolar tissue, retains impressions made upon it for a long time. The waxy liver ( ^Vachskher) formerly described by Home, constitutes ' The nutmeg-like appearance which the liver assumes under such circumstances becomes the more marked, the greater the deposit of pigment in the cells around the central veins and the larger the quantity of blood contained in these veins. The same alteration of colors is observed in consequence of obstruction of bile. where the deposit of pigment in the cells always takes place first around the central veins of the lobules. It is also observed, with somewhat different shades, to be produced by irregulari- ties in the distribution of blood, and by congested states of the roots of the hepatic veins, which are of such frequent occurrence. Hence the nutmeg-like appearance of the cut surface can only be employed for the diagnosis of fatty liver with great cau- tion ; we have to distinguish between a fatty, a pigmentary, and a hyperasmic nutmeg liver. - It is much more difficult than ia usually believed to distinguish between the cen- tral and peripheral portions of the lobules, inasmuch as very different appearances are produced, according t-o the direction in which the section of the bloodvessels passes. The matter is only to be decided by injecting different colored substances into the blood-vessels. ON DISEASES OF THE LIVER, 209 an apparent exception to the characters just described, being romarkable for its great hardness and firmness. This form of disease usually belongs to the so-called colloid orlardaceous degeneration of the gland; but there are cases in which the cause of the abnormality must be attributed to the de- position of fat of a firm character.' When we compare the ethereal ex- tracts of different fatty livers with one another, no small differences may be observed in respect to the consistence of the fat. No quantitative analysis, however, of the amount of margarine has yet been made. Lastly, we would mention one other peculiar form of fatty deposit of rare occurrence, viz.: — that which has its seat principally in Glisson's cap- sule, and following the course of this and the blood-vessels penetrates deep- ly into the substance of the liver. I have seen this abnormal condition developed in a high degree in one individual, who died from obliteration of the portal vein. In this case, the trunk of the portal vein, before its entrance into the liver, was closed up by the compression of collections of pus in the surrounding areolar tissue. No fat was observed to be depos- ited in the secreting cells. V. — Frequency with which Fatty Liver occurs. It will be seen from the previous remarks on the causes of fatty liver, that higher or lower grades of this alteration of structure are not unfre- quently met with. In order to obtain accurate and reliable data as to the frequency of occurrence of fatty liver, this gland has been for a long pe- riod examined for fat at the autopsies in All Saints' Hospital, and always with the microscope.; sufficient information on the point cannot be derived from simple inspection. The results of 466 examinations of this nature are collected in the annexed Table. Considering the powerful influence exercised by the habit of living, it should be mentioned, that these cases strictly refer only to Breslau, and to the class of the community who are wont to seek refuge in public hos- pitals; in connection with which we must observe, that hepatic affections generally are of frequent occurrence both here and in the neighboring Sclavonian provinces. The frequency of fatty liver in other countries can only be determined by direct examination. So far as I can trust my mem- ory, I have seen this affection less frequently in Gottingen than in Hol- stein and Silesia; it has also appeared to be more frequent in summer than in winter.* ' Laennec, Traite de V auscultation, Tom. VI., p. 36. - As regards the different grades mentioned in the Table, I understand by fatty liver of the highest grade (l. ) those forms in which the deposit extends through all the hepatic cells as far as the centres of the lobules. Under the second heading, I reckon those in which the cells are found copiously infiltrated, at least halfway, to the centre of the lobules. It is obvious, however, that we cannot define these different grades with great precision. Vol. I.— U. 210 A CLINICAL TREATISE Tabulak View of the Occureence of Fatty Deposit in the Livee, IN different Diseases, determined by Microscopic Examination. I. Fatty n. m. TV. Proiwrtion between Liver of CellB Quantity Cells fr«.4-«i the number of the the rich in | of Fat free from J Cases I. and u. and the highest Fat. BmalL FaU total number. grade. i 1 1 f 7 o » m o 8 Diseases. 1 o 0? 1 1 a ■s 6 i 1 1 B 1 m o i 1 8 1 Si 5 J 1. Tubercular Affec- tions 17 9 8 62 33 ^ 34 25 9 4 3 1 117 70 47 1:1.48 1:1.66 1 :L27 2. Pulmonary Em- physema — 6 8 2 3 4 5 5 20 8 12 2 8 2 14 I 10 1 4 18 42 6 25 7 17 1 : 2.16 1 : 5.25 1 1 3.00 8.a3 1 : 1.75 3. Pneumonia 1:3.40 4. Pleurisy 1 1 — 10 2 8 4 16 2 10 2 6 1 9 1 5 4 6 35 4 17 2' 18; 1:6.00 1 : 3.50 1 1 4.00 8.50 5. Heart Disease. . . 1:2.25 6. Bright's Disease. 1 1 8 6 2 7 5 2 3 3 ' 19 15 41 1 : 2.11 1 2.14 1:2.00 7. Typhus 1 1 6 3 3 21 12 9 16 13 3 44 29 15' 1:6.28 1 7.25 1:5.00 8. Pyiemia 3 2 1 3 2 1 5 5 1 2 2 13 9 4' 1 : 2.16 1 2.25 1:2.00 9. Variola 1 — 1 7 4 3 14 10 4 7 5 2 29 19 10 1 : 3.62 1 4.75 1 :2.50 10. Intermittent Fe- ver and its Seque- Iffi ....- 6 4 2 S 3 3 3 12 7 5 1:2.00 1:L75 1:2.50 11. Diabetes — _ — — 1 1 ! 4 8 1 5 4 1 — — — 12. An*mia and In- anition from Hae- morrhage, Ulcer of the Stomach, Stricture of the G^sophagus, ii'c. . . — 5 3 2 3 — 3 2 2 10 5 5 1:2.001:1.661:2.50 13. Senile Marasmus, t 1 Apoplexy 1 1 8 1 7 8 8 5 2 1 1 19 6 13 1 : 2.11 1:3.001 : 1.&5 14. Cancer — — 2 7 1 5 I 11 5 4 4 7 1 8 2 2 2 6 21 14 7 11 141 3 1:10.50 1:7.00 1:14.00 1.5. Delirium tremens 1 : 2.00 1:2.20 1:L50 10. Constitutional Sy-' i philis — _ 6 3 3 2 2- — 8 5 8 1 : 1.83 1:L66 1:L00 17. Chronic Atrophy i of Liver 1 1 2 1 1 o 2:—! 2 1 1 7 5 2 1 : 2.33 1:2.50 1:2.00 18. Lardaceous Liver 1 in the stage of Colloid inliltra- tion — 3 1 — — — 1 1 4 3 1 1 : 1.38 1:1.33 1:1.00 ]0. Cirrliosis of Liver 2 1 1 7 4 3 4 3 1 — — 13 8 5 1:L44 1:L60 1 :1.25 20. Oh>truction of 1 I!Ua ' 1 — 1 4 2 2 4 3 1 9 5 4 1 :9.00 — 1:4.00 21. Cancer of the Liver — — — 6 8 1 3 8 2 1 9 5 4 — — 22. Individuals who have died sudden-. ly without previ- ous disease 2 1 1 4 3 1 2 1 1 8 5 3 1 : 4.00 1:5.00 1:3.00 2;;. Xew-bnrn Infants and Children dur- intr the first weeks' ' of life 28 5 164 1 3 i 2 3 1 2 1 1 i 9 466 275 4 1 : 1.80 1:1.66 1 : 2.00 1 Total 17 11 81 182 i 115 S 92 1: 3.02 1:3.57|1:2.25 ON DISEASES OF THE LIVER. 211 it appears, tben, from this Table, that out of 466 bodies, fatty liver attained its highest grade in 28, or in 1 out of 16.6 cases; and that the hepatic cells were found rich in oil in 164 cases, or in about one-third.' Females are more frequently affected than males with this morbid change in the parenchyma of the liver, the proportion in the latter sex, being as 1 to 3.5, and in the former as 1 to 2.2. In healthy individuals, who have died suddenly from accident, the proportion was 1 to 4; in men, 1 to 5, and in the women, 1 to 3. Under certain physiological conditions, there is an increased tendency to the deposit of fat in the liver, as in newly- born infants and in children, during the first few weeks of life, where the proportion was 1 to 1.18. In infants who continue taking the breast until death, the hepatic cells are usually rich in fat, as they likewise are in sucking animals.* In pregnant and puerperal females also we very fre- quently find fatty deposits in the liver. Among the pathological conditions which influence the development of fatty liver, tubercle of the lungs stands first; of 117 cases of this affec- tion, in 17 there was the highest grade of infiltration, and in 62 the hepatic cells contained much oil. The proportion was as 1 to 1.48: in males, as 1 to 1.66, and in females, as 1 to 1.27. Next in order comes the drunkard's dyscrasia. Of 13 individuals who died of delirium tremens, in 6 the liver was very fatty, in 3 the organ contained little fat, and in 2 none at all; lastly, 2 died of cirrhosis of the liver. Constitutional syphilis was in 8 cases always accompanied by a more or less fatty liver; three times the infiltration attained a high degree, and twice lardaceous matter {Speckstoffe) could be detected. When we compare other pulmonary diseases with tubercle, the ratio is found to be entirely different; in pneumonia it was as 1: 52; in pleurisy, 1: 6; in emphysema of the lungs, 1: 2.1. But of 35 observations of heart disease, the frequency of fatty liver was as 1 to 3.5. Fatty liver made its appearance more frequently with Bright's diseases (1 : 2.1) and with intermittent fever and its sequelse (1: 2). It was an equally frequent ac- companiment of senile marasmus, and of inanition from haemorrhage, diseases of the stomach, &c. The comparative frequency of fatty liver in the cancerous cachexia (1 : 10.5) was remarkably small when contrasted with that observed in tubercle (1 : 1.4). Fatty liver of the highest grade was repeatedly observed in acute dis- eases of a general nature, such as typhus, variola, and pyaemia; of three cases of erysipelas ambulans, this condition of the liver was met with in all. Among the local diseases of the liver, cirrhosis and the lardaceous liver {SjoecJcleber) are remarkable for the amount of fat which they con- tain. The smallest quantity of fat in the liver occurred in diabetes melli- tus. In several cases of stricture of the oesophagus, leading to prolonged abstinence, every trace of fat had disappeared; this was also the case in an individual who had been bedridden for years on account of hemiplegia; ' This proportion must, as a general rnle, be somewhat too great, because, of the 466 cases, 117 were tubercular subjects, who are remarkable for the frequency with which fatty liver is met with in them. * This circumstance has been already noted by Gluge {AtXas der path. Anat., Lief. 1) ; and more recently by Kolliker ( VerJiandl. der physik. med. Oesellschaft in Wui"*- burg, Bd, VIL, Heft 2). 212 A CLINICAL TREATISE — a proof that bodily rest does not alone suflSce for the production of fatty liver. When we compare these results with the observations of Louis and others, we find that there are important discrepancies. Louis found, out of 230 individuals who died of acute and chronic diseases, excepting pul- monary tubercle, that fatty liver only existed in 9, and of these 9 there were 7 of a tubercular diathesis; whilst out of 120 persons who had died of phthisis, 40 had fatty liver. Home, in Edinburgh, observed fatty liver 15 times out of 65 phthisical persons, and these 15 were exclusively females. I believe, myself, that these remarkable discrepancies must mainly depend upon the fact that, without the assistance of the micro- scope, it is impossible to form a correct opinion as to the amount of fatty matter contained in the liver; moreover, a certain amount of influence must be exerted by the different modes of living, as also by the nature of the treatment to which the patient has been subjected, as for example, whether cod-liver oil has been used or not. VI. — Pathological Importance of Fatty Liver. Various opinions have been entertained as to the nature of fatty liver, and as to its effects upon the entire organism, according to the manner in which it has been supposed to originate. Most observers have classi- fied this structural change with those derangements of nutrition which are wont to be included under the name of atrophy. Andral,' Thomson, Barlow,' Cruveilhier,' Wedl, Henoch, and others, are all influenced by this view of the matter in their opinions concerning fatty liver, although they differ as regards the more remote causes of the atrophy. Henoch * speaks of the deposit of fat in the hepatic cells as a degeneration of the epithelium and other elementary tissues, which takes place in consequence of congestion and exudation. Lereboullet ' blames a defective organic combustion as the cause of the impaired nutrition of the hepatic cells. There are unquestionably forms in which the fatty degeneration must be regarded as resulting from a deranged nutrition of the secreting cells. The appearance of the fat is here preceded by an infiltration of the cells with an abnormal plasma, or by some other derangement of their nutrition, which gives rise to a retrograde development, and to the transformation of the cell contents into fat. When this process has terminated, the cells almost always lose their secreting functions. But in by far the larger number of cases of fatty liver, this explanation is inapplicable. The fat is taken up as such into the cells from without; this imbibition is intimately associated with the functional activity of these structures; it rises and falls according to the nature of the food, the quantity of fat contained in the blood, the more or less active nature of the secretion of the gland, &c. ' Clinique Mcdicale, Tom. II., p. 240. "^ On Fatty Degeneration, 1853, p. 9 : — " This organ degenerates from general atrophy." '■^ Anat. PaVi. Gener., Tom. III., p. 292. Paris, 1856. "La metamorphose adi- peuse du foie n'est done autre chose qu'une atrophic adipeuse, bien qu'elle s'accom- pagne constamment d'une augmentation de volume de cet organe." ■» Klinik der Unteiieibskrajikheiten, Bd. I., S. 122. '" Op. cit., p. 112. " Le dcveloppement de la graisse dans ces cellules parait etroite- ment lie a uu ralentissement dans le travail nutritif, et a la combustion organique, qui est la premiere condition de ce travaU." ON DISEASES OF THE LIVER. 213 The liver serves here as a temporary reservoir for the surplus fat which has been absorbed; functional derangements do not ensue until the overloading of the cells with fat, by compressing their other contents, and by impeding the circulation in the portal vein, begins to affect the metamorphosis of matter in the cells and to interfere with the secreting function of the gland. All these injurious results disappear as soon as the chief portion of the fat deposited is reabsorbed. It is impossible to define accurately this physiological change in the structure of the liver from one which would amount to disease. vn. — Effects of the deposited fat upon the Function of the lAver, and upon the entire System. — Symptoms of Fatty Liver. The conditions of the system under which fatty liver is met with, and the relations of fat to the due performance of the functions of the liver, show that moderate accumulations of this substance may exist without giving rise to pathological derangements. We should rather regard as a sign of disease, a complete absence of oil globules in the hepatic cells, such as is particularly the case in diabetes mellitus. The deposits arising from the absorption of food come and go, according to the nature of the food, and the consequent amount of fat contained in the blood. They only attain a high grade, when they have been brought on by a long con- tinuance of improper habits of life. The forms of fatty liver which depend upon consumptive diseases, the drunkard's dyscrasia, and other more radical changes in the composition of the blood, or which originate from local changes in the parenchyma of the liver, impairing the nutrition or the functions of the cells, are more persistent in their duration. These forms, therefore, more frequently ar- rive at such a high grade as to impair the functions of the organ. Considerable accumulations of fat in the hepatic cells derange the functions of the liver in many ways; but it is only in rare cases that they suspend it entirely, or impair it to such an extent that the entire system suffers. In the first place, they act mechanically by impeding the flow of blood through the portal vein, and the excretion of the bile. Owing to the cells becoming distended with fat, the vascular meshes in which they lie become enlarged, and the calibre of the capillaries is in a corresponding degree narrowed. Hence, as a rule, the advanced stage of fatty liver is found to present an anaemic aspect.' The circulation, how- ever, is never impeded to any remarkable extent, inasmuch as the soft fluid fat appears to yield before the pressure of the blood; the vessels in a fatty liver are usually injected with ease. The obstruction to the circula- tion of blood is very seldom so great as to give rise to dropsical effusions to any amount; it is, however, sufficient to produce chronic congestion of the gastro-intestinal mucous membrane, which, from slight causes, may be- come exaggerated into catarrhs, derangements of digestion, diarrhoea, and iiiiemorrhoides. The enlarged vessels which are frequently seen running through the serous coat in a similar manner as in cirrhosis, prove that the flow of blood may become obstructed in fatty liver of a high grade. En- ' Even the sections of the larger vessels, seen upon a cut surface, not unfrequently, as Cruveilheir has already observed, present an angular in place of a rounded outline, in consequence of the unequal lateral compression of the swollen glandular tissue. 214 A CLINICAL TEEATISE largements of the spleen, however, are rare; this organ remains of its me- dium size, and is smaller on an average than in the case of the lardaceou8 liver and in cirrhosis. (See Table IV,, p. 20.) Besides the impeded circulation of blood, we constantly observe, that the excretion of bile becomes obstructed. The hepatic cells in the vicin- ity of the central veins are always loaded with pigment, they contain a large number of yellow granules, and not unfrequently are infiltrated with a brownish or yellowish homogeneous matter. The same cause which compresses the capillaries also impedes the entrance of the bile into the commencement of the excretory ducts at the periphery of the lobules.' This derangement also seldom exceeds a certain point; it never reaches such a degree as to give rise to an intensely jaundiced hue of the skin. In simple fatty infiltration of the gland, it is rare for the functions of the liver — in so far as these influence the metamorphosis of matter, and manifest themselves in the secretion of bile, and in the composition of the blood — to be deranged to any great extent, although there are anomalous cases which must not mislead us. Symptoms of advanced antemia or hy- dra?mia, such as are observed in lardaceous degeneration and in cirrhosis of the liver, are here only met with in exceptional cases; we must not, however, overlook the fact that pasty-looking individuals afflicted with fatty liver, bear losses of blood and other debilitating agencies badly. Out of a large number of instances in which the parenchyma of the liver was examined for sugar, this substance was found in most cases, even when the deposit of fat was very considerable; occasionally it was absent, as happens even in the case of the healthy gland, whenever death has been preceded by a disease which entails prolonged abstinence. Thus the accumulation of fat in the liver does not arrest those processes which give rise to the formation of sugar. There can be no doubt, however, that the metamorphoses of matter which take place in the interior of the cells, are altered and impaired by the presence of fat in place of the other contents of these cells. This opinion is favored by the feebly acid char- acter of a decoction of the liver, and by the presence of abundance of leucine. Additional evidence as to the modifications of the metamor- phosis of matter resulting from fatty liver may be expected from further examinations. It is a difficult matter during life to judge of the quantity of bile se- creted. The color of the fa?ces furnishes only an uncertain indication of the quantity of this secretion which is formed within a fixed period of time. The color may be but slightly altered, even in cases where there is a very remarkable diminution, or a complete cessation of the secretion. In the slighter deviations from the normal amount of bile, there is no correspond- ing alteration in the color of the fteces, and the less so, as the latter is in- fluenced not merely by the quantity of bile, but also by the activity of the intestinal absorption, and by the length of time that the bile is retained in the intestinal canal. When we consider the small quantity of yellow matter which is contained in the hepatic cells (which is the more remarkable, the greater the deposit of fat), and when we further consider the above-mentioned alterations in the chemical characters of the gland, ' Occasionally the larger ducts also appear to be compressed. Under such circum- stances. I have repeatedly- observed, in advanced stages of fatty liver, sacculated en- larg-cirients of the ducts filled with thickened bile. In one case, numerous crystals of hseiaatoidine developed themselves in the decomposed bile contained in such a sac. Cruvcilhier describes a similar enlargement of the ducts in a fatty liver. {Anat. Pa- thol. Gejiir., Tom. III., p. 230.) ON DISEASES OF THE LIVER. 215 as also the experiments of Bidder and Schmidt, who found that the infil- tration of the hepatic parenchyma with fat, consequent upon feeding ani- mals with fatty food, reduced the secretion of bile to the same condition as in starving animals, we are justified in assuming a diminution of the secretion as a result of fatty liver. The 2^ost-morte)n appearances also, which are found in cases of very advanced fatty degeneration, coincide with such an opinion. In two cases of this nature, I have found the bile ducts empty, and covered with a grayish-yellow mucus; the faecal matter in the small and large intestines was ash-colored. A complete cessation of the secretion, however, is rare.' I have not been able to detect any important changes in the quality of the bile secreted in a fatty liver. It only presents those variations of col- or and consistence which are dependent upon a greater or less degree of concentration, a shorter or longer retardation in the gall-bladder, and the secreting activity of the mucous lining of the bile ducts. It may be pale and thin, or at another time dark, thick and viscid. Albumen, which was found by Thenard in five out of six cases, I have never met with; neither have I ever observed the large quantity of oil mentioned by Lereboullet. Addison" has remarked, that the bile is characterized by a peculiar odor, which is developed upon the addition of acids. This, he says, is perhaps the most disagreeable and intolerable odor which is ever emitted by animal matter, and can be compared to no other. I have never my- self been able to perceive any increase of that peculiar odor, reminding one of fjecal matter, which is exhibited by thickened bile. The opinion, therefore, which seemed to me a probable one, that under such circum- stances, a stinking fluid fatty acid might be present in the bile, is not con- firmed.* viii. — Diagnosis. From what has been above stated it will be understood, that the symp toms which accompany fatty liver, and which in practice must furnish the * The statements of Lereboullet (op. cit., p. 100), who observed the characters of the bile in geese, which had been fed with the object of producing fatty livers, have an im- portant bearing upon this matter. After nine days' feeding, the gall-bladder was dis- tended with green bile, containing a moderate quantity of oil-globules. After 28 days, however, it was small and puckered, and contained a very small quantity of oleaginous bile, in which flakes of mucus and numerous oil globules could be detected. '^ Guy's Hosp. Reports, I., p. 478. ' I have repeatedly determined the amount of oil which is contained in the secretion of the gland, when its tissue is infiltrated to a great degree. The ethereal extract of the dried bile in no case exceeded 0.50 per cent., usually it amounted to from 0.33 to 0.38 per cent., the solid residuum being from 13.1 to 33.6 per cent, of the entire quan- tity of bile. The bile was of acid reaction, and contained an oily fat along with cho- lesterine. In many cases, the ethereal extract presented a pale, blood-red color, and upon evaporation, left behind a peculiar crystalline coloring-matter. This consisted of reddish-yellow lancet-shaped leaflets, which were partly isolated and partly imited in arborescent groups. Along with these, an amorphous pigment, presentLog, upon exposure to the air, the play of colors characteristic of chroraogen, was not unfrequently present. I have not yet succeeded in collecting a quantity of the crystals sufficient for analysis. (These have since been ascertained by Valentin to be crystals of hsema- tine. and not at all peculiar to the bile of fatty liver. See Preface. — Transl.) Moreover, they are by no means peculiar to the bile of fatty liver ; they have not un- frequently been absent in it, and have been observed under other conditions, as, for in.stancc, in cholera. The coloring-matter of the bile of fatty liver, in other respects, presents the usual characters. In one case, hydrochloric acid produced the same play of colors as nitric acid. 216 A CLINICAL TREATISE data necessary for diagnosis, are usually of a very uncertain character, and from the nature of the subject must still remain so. The slighter forms of the disease, which can scarcely be regarded as of a pathological nature, give rise to no remarkable derangements; in the more advanced grades of the affection, the symptoms are of such a nature that they can only, under fav- orable circumstances, be appealed to with confidence. The first which is of service, in a diagnostic point of view, is the alteration in size and form which the liver is wont to undergo when the accumulation of fat is con- siderable. The diameter of the gland from behind forwards increases, and at the same time the organ becomes flabby and shrivelled (welk), bends upon itself and sinks downwards: — two conditions which equally contrib- ute to increase the extent of the dull percussion sound, and to remove the anterior margin to a greater or less depth below the margin of the false ribs. Owing to this sinking of the anterior margin, a fatty liver upon ex- amination appears to be larger than it really is. When the abdominal parietes are soft, and not too thick to permit of palpation being practised with effect, we can feel the rounded margin of the liver, and also make out its soft consistence. The positive value of these signs is not slight, but their absence is altogether without importance, inasmuch as these changes in the size and form of the gland are by no means constant. A second indication for the diagnosis of fatty liver is furnished by the de- rangements which arise from the interruption of the circulation through the portal vein. The complex train of symptoms so frequently described by the older authors, under the title of " abdominal plethora," and which occur in incipient cirrhosis, and in other mechanical obstructions to the flow of blood through the portal vein, are met with here in a more or less marked form: — such symptoms, for example, as an impaired gastric and intestinal digestion, associated with the development of gases, distention and tenderness of the epigastric region, irregular, and usually constipated bowels, a hypochondriacal frame of mind, hajmorrhoids, &c. The ftBces are at one time dark, at another, pale and clay-colored; occasionally we observe in cases of fatty liver, an undue tendency to diarrhoea, — a circum- stance which was noted 3'ears ago by Schunlein. I have had repeated opportunities of examining the bodies of individuals, who during life have had a pasty complexion, who had been wont to suffer from profuse diar- rhoea from trifling causes, and in whom death has taken place suddenly from apoplexy, or, in one case, from acute pulmonary oedema, and have found nothing abnormal in the abdomen, with the exception of a fatty liver in an advanced stage. Similar observations have been repeatedly made at the j^ost-mortem examinations in hospital practice. In the same way, we frequently find fatty liver in overfed children, who die from ex- haustion, after profuse pale diarrhoea.' The skin has been found by Addison altered in such a manner, that were the change constant, it would be of great value in diagnosis. It was pale, an;x?niic, seniitransparent, and waxy, and at the same time soft and smooth to the feel, like satin. The paleness was at one time devoid of color, and at another dirty-yellow; it was most distinctly marked in the skin of the face, but was also present in other localities. Such changes of the skin are not unfrequentlv observed in females laboring under tubercle (I have frequently seen them myself), where of course fatty liver was present, as it usually is in pulmonary phthisis; but I am unable ' Leg-endre also has observed diarrhoea in children, in connection with fatty liver ; and Bright has counected both diarrhoea and amenorrhoea with it. ON DISEASES OF THE LIVER 217 to state whether the liver is the cause of the change or the hectic fever with its profuse sweating; at all events, fatty liver of an advanced grade is met with, without the skin presenting this character. In drunkards with fatty liver, the skin has not unfrequently a greasy, fatty feel; owing to the abundance of fat contained in the blood, the cutaneous secretion be- comes loaded with fatty matter, in a similar manner to what takes place from the continued use of large doses of cod-liver oil (where the odor of the cod oil is transmitted through the skin by fatty acids in a fluid state), and to what was observed in dogs fed by Magendie upon butter. A due regard to the recognized causes of fatty liver is of greater im- portance in diagnosis. Where an enlargement of the liver is detected in persons laboring under tubercle, in drunkards, or in individuals of a tor- pid luxurious habit of life, and when this is associated with the conse- quences which are known to result from obstructed circulation in the por- tal vein, then the individual symptoms acquire a greater weight than under other circumstances would belong to them. Cases, however, are met with, where the derangements to which fatty liver gives rise, are of a much more marked character; the secretion of bile becomes more and more diminished, extreme ana^mia comes on, until at length death supervenes under symptoms of increasing exhaustion, or of complete acholia. This train of symptoms is very seldom observed, and only in the excessive grades of fatty infiltration (See Observation No. XXII., p, 172); it occurs more frequently with the fatty degeneration of the gland, which takes place after the parenchyma becomes infiltrated with colloid and other exudations, sometimes along with lardaceous spleen, and at other times independently of this. The organ, which at first is en- larged, is gradually reduced to even below its normal size; its outer sur- face continues smooth, or becomes slightly granular, the bilious color of the stools becomes paler, and the appearance of the patient assumes more and more the characters of general cachexia. Under such circumstances, the liver is found to be of normal size, or somewhat smaller, its cells are filled with fat or albuminous granules, the parenchyma is sometimes traversed by bands of newly-formed areolar tissue, and the bile ducts contain but little secretion. Frequently, but by no means always, the parenchyma of the spleen, or kidneys, or sometimes of both organs are infiltrated with lardaceous matter, not a trace of which can be found in the liver. When other important organs, such as the spleen, lymphatic glands, and kidneys, are found diseased as well as the liver, it is a difficult matter to determine the share which the liver takes in the generation of the symp- toms of general derangement, the cachexia, hydraemia, &c. In many cases, however, the kidneys and lymphatic glands are free from disease, and the spleen is only changed to such a slight extent, that the symptoms must be mainly attributed to the fatty degeneration of the liver. The diagnosis of fatty degeneration during life is often attended with great difficulties, especially when one has not the opportunity of tracing the entire development of the process. The following symptoms are often of great service for this purpose: — the diminution in volume of a prima- rily enlarged liver, along with increasing cachexia, a smooth surface of the gland, the co-existence of chronic enlargement of the spleen, the de- crease of the biliary secretion, and the presence of those predisposing causes which experience shows to give rise to the colloid and lardaceous infiltration of the gland, such as intermittent fever, constitutional syphilis, diseases of the bones, &c. 218 A CLINICAL TREATISE I shall only record here one instance of this nature, but, for addi- tional illustrations, I refer to the chapter on Lardaceous Liver (Speckleber). Observation No. XXXI. Persistent Intermittent Fever. — Ancemia and Hydrmmia. — Exhausting Diarrhoea, with but little Bile in the Stools. — Death under Cerebral Symptoms. — Fatty Degeneration of the Liver. — Small Lardaceous Spleen. — A limited Cancerous Ulcer in the Caecum. J. Pallifka, aged 31, during July and August, 1853, was treated in the Clinique for anaemia, without benefit. He was a large, broad-shouldered man, of a pale, waxy countenance, and complained of remarkable weak- ness, accompanied by wandering pains and deranged digestion. At the origin of the aorta, there was heard a systolic bruit, which was propa- gated into the carotids; lungs healthy; spleen and liver of normal size; the tongue slightly coated; the bowels were moved two or three times in the day, and the stools were of a pale color; urine had a specific gravity of 1012, and was free from albumen. Under the use of the preparations of steel, the ethereal tincture of the muriate of iron, the lactate of iron, &c., the appetite increased; but the paleness, the feeling of weakness, and the other symptoms of anaemia, remained unchanged, notwithstanding a full diet. The patient left the Hospital, and did not return until the 16th of February, 1854. The anaemia had now increased to hydnemia; anasarca and ascites had supervened; there were from six to ten thin pale stools daily; a tender induration, which, however, was not very accurately cir- cumscribed, could be felt upon palpation in the caecal region; urine 1007, pale and without albumen; blood drawn off by a cupping-glass showed no increase of the white corpuscles. Vegetable and mineral astringents, nux vomica, »S:c., were administered in vain to check the diarrhoea. On the evening of the 25th, loss of consciousness set in suddenly, the speech be- came stammering, the features distorted, and the eyes fixed and staring; pupils dilated; pulse slow and thready; the respiration slow and feeble. On the 26th he died. Autopsy. The contents of the cranial cavity presented nothing abnormal. The bronchi were empty, and the lungs very oedematous; the heart appeared unchanged in its muscular tissue and valvular apjDaratus. About four pounds of clear serum were found in the abdominal cavity. The mucous membrane of the stomach and of the small intestine, as far as the ileo-c£e- cal valve, was pale. The caecum over its greater extent was firmly adhe- rent to the fossa iliaca, and its mucous membrane was partially converted into an ulcerated surface of a dirty-gray ragged character; the walls of the c;eeum presented a pulpy infiltration about five lines in thickness. The lower portion of the intestinal canal, as also the retro-peritoneal glands remained intact. The spleen was slightly enlarged, five inches long, and three in breadth; its consistence was firm, and its cut surface glistening. Til i liver was of normal size; its surface was smooth, and its margins sliarp: the secreting cells had an irregular outline, and most of them con- tained no nucleus, but were filled with fine granules and drops of oil, and ON DISEASES OF THE LIVER. 219 some of them also with brown pigment. The gall-bladder contained a small quantity of yellow mucus, and in the gall ducts within the liver were aggregated masses of cylindrical epithelium of a gray color. The liver contained no sugar, but large quantities of leucine and tyrosine. The patient attributed his illness to an obstinate intermittent fever, from which he had sujffered during three months, 2^ years before his death. The altered conditions of the spleen and liver, which must be regarded as constituting the starting-point of the anaemia, apparently dated from that period. The spleen, which was scarcely enlarged, was in a state of larda- ceous degeneration, and the liver was affected with fatty degeneration, such as we find as a final result of infiltration of the parenchyma with albuminous matter, in consequence of malarious poison, constitutional s^-philis, &c., which may or may not be accompanied by lardaceous degen- eration of the spleen, kidneys, and lymphatic glands. The functions of the liver under these circumstances were in a great measure destroyed, and. the results, which the suspension of these functions entails upon the entire system, ensued. The limited cancerous deposit in the caecum, which did not make its appearance until the symptoms of anaemia had already existed for two years, might have contributed to expedite the death from exhaustion, but could not be regarded as the cause of the poverty of blood. In the present state of our knowledge, the diagnosis of fatty infiltra tion, like that of fatty degeneration, is in many cases uncertain. The dis- advantage arising from this, however, in medical practice, so far as it con- cerns the former condition or the simple fatty liver, is not very important, inasmuch as the affection very seldom comes under treatment. The slighter forms exist without causing any important derangement of the general system; the more advanced forms, such as react injuriously upon the system, are often associated with other dangerous morbid conditions, as, for instance, pulmonary tubercle, which make the treatment of the he- patic affection a very secondary matter. The cases in which the liver af- fection exists per se are usually the result of improper living, hereditary predisposition, &c. ; they may be recognized with some degree of certainty from the etiological agencies which give rise to them, in connection with the diagnostic measures already described, either directly, or by way of ex- clusion. IX. — Treatment, The treatment of fatty liver, which has for its object the diminution of the fatty contents of the liver, may be regarded in several points of view. First comes the regulation of the diet: fat and amylaceous articles of diet, as well as spirituous liquids of every sort, should be avoided ; fruits are beneficial, as well as those vegetables which are rich in pectine,' and in compounds of the alkalies with the vegetable acids, and also the lean flesh of young animals; active exercise in the open air is to be en- joined, and in short, a mode of life which shall have the effect of hasten- ing the metamorphosis of matter. Those medicinal agents are best suited for the diminution and removal of the fat deposited in the hepatic paren- chyma, from which, so far as our present experience in this matter extends, * These are c.irrots, turnips, aud some pulpy fruits, such as apples, pears, red cur- rants, &C. — TUANSL. 220 DISEASES OF THE LIVER. we may expect an increase in the secretion of bile.' In the choice of med- icines, we must attend carefully to the condition of the digestive organs, and must avoid everything, by the persistent use of which the functions of these organs might be deranged. In the slighter forms of the affection, it is sufficient, along with a regu- lated mode of life, to administer the bitter vegetable substances abound- ing in alkalies, such as the extract, saponar.,' the extract card, benz.,' ex- tract of taraxacum, extract of chelidonium,* &c., either alone or in com- bination with alkaline carbonates, or the compounds of the alkalies with vegetable acids; we may also recommend rhubarb, or aloes, when there is great torpidity of the bowels. In the more advanced forms, it is usually necessary to have recourse to the waters of Karlsbad, Marienbad, Homburg, or Kissingen,' of which that should be selected which is most suited to the individual case, to the general symptoms, and to the degree of derangement of the functions of the gastric and intestinal mucous membrane. When there is a marked tendenc}- to diarrhoea, it is best to avoid all the springs just mentioned, and to employ in their place the springs of Eger," or Ems.^ In anaemic individuals, the easily-absorbed preparations of steel, such as the lactate and carbonate of iron, or, better still, small quantities of the waters of Spa, or Schwalbach," are not unfrequently necessary. When there is per- sistent exhausting diarrhoea, we must have recourse to the vegetable and mineral astringents. The treatment of fatty degeneration of the liver is mainly preventive and symptomatic; the object here is to avert as soon as possible the cir- cumstances which may lead to the liver becoming infiltrated with albumi- nous matter, and to remove this substance before the nutrition of the cells becomes impaired. Constitutional syphilis, rickets, and other diseases of the bones, the marsh poison, &c., are to be combated by an appropriate treatment; the infiltration of the liver is to be removed by means of iodide of potassium, iodide of iron, the alkalies, and the waters of Karlsbad and other similar springs. It is seldom that we succeed in accomplishing this last indication. I have seen the volume of the liver reduced by such means, but at the same time the symptoms of degeneration often super- vened in a threatening manner. When this is the case, the prognosis is unfavorable, and deobstruent medicines are then prejudicial; the treat- ment must now be confined to the use of the weaker preparations of steel, a bland nutritious diet, and those remedies which are best adapted to reg- ulate the digestion of the stomach and bowels, such as bitter vegetable substances, &c. ' Few of the observations bearing on this point, which we possess, can be depended upon. It is only in recent times, that the experiments which have been made upon an- imals by means of biliary fistuke, have furnished some reliable data. The information, however, which has been derived from this source, is still far from sufficient to meet the demands of treatment. ■-' Prepared from the root of the Saponaria officinalis^ or soapwort. — Transl. ^ Extract prepared from the leaves of the Carcluus benedictus, a species of thislle. — Transl. * Cheli(hnium majus^ or celandine. — Transl. ^ See note, page 88. * The Springs of Egcr, in Bohemia, are saline chalybeates, and contain a consider- able amount of free carbonic acid. The solid constituents consist of the sulphate and carbonate of soda, chloride of sodium, and carbonate of iron. — Transl. ' See note, page 88. '^ See note, page 85. APPENDIX. APPENDIX OV 0BSEBVATI0N8 AIJT) EXPERIMENTS IN SUPPOBT OF TIIB STATE- MENTS MADE IN THIS "WORK. I. Observations of Disease. No. I. {Page 40.) Tertiary syphilis — Tumor of the liver, which as- cended as high as the second rib, and consisted of echinococci, together with lardaceous infiltration — Bulging and fluctuation of the intercostal spaces — Displacement of the heart — Immobility of the tumor upon deep inspiration — Diagnostic value of exploration by a trocar. No. II. {Page 46.) Cancer of the small omentum — Compression of the portal vein and atrophy of the liver — Ecchymoses in the serous coat of the intestines and in the parietal peritoneum. No. III. {Page 53.) Cancer of the right kidney — Displacement of the liver upwards and to the loft. No. IV. {Page 73.) Pneumonia duplex — Icterus — Bilious stools — Green expectoration, continuing for ten days after the cessation of the pneumonia, and for eight days after the disappearance of the jaun- dice from the skin. No. V. {Page 93.) Dyspepsia — Symptoms of chronic simple ulcer of the stomach — Jaundice — Distention of the gall-bladder — Pleurisy on the right side — Dropsy — Petechiae — Death. Cancer of the duodenum and dilatation of the bile ducts — Simple ulcer of the stomach — Exudation in the right pleural cavity. No. VI. {Page 96.) Cancerous deposit in the head of the pancreas and in the duodenum — Occlusion and widening of the bile ducts and of the pancreatic duct — Distention of the bile ducts with mucus and bile — Dysentery — Diminished secretion of urine — Infiltration of the kidneys with solid deposits of bile-pigment — Death from exhaustion. No. VII. {Page 103.) Cancerous deposit in the head of the pancreas — Occlusion of the ductus choledochus and of the pancreatic duct — Enlargement of the pancreatic duct and of the bile ducts — Jaun- dice — Intestinal haemorrhage — Diabetes mellitus — Dysentery — Death from exhaustion. No. VIII. {Page 106.) Closure of the ductus choledochus by neAvIy- formed areolar tissue, the result of peri-hepatitis — Jaundice and enlargement of the bile ducts — Dropsy — Secondary pneumonia — Death. 224 APPENDIX. No. IX. {Page 114.) Contusion of the pelvic bones — Rigors — Somno- lence — Jaundice — Albuminuria — Death. Phlebitis of the pelvic veins — Metastatic deposits in the lungs — Soft anaemic liver. No. X. {Page 115.) Acute articular rheumatism — Endocarditis — Re- peated rigors — Painful enlargement of the spleen — Jaundice — Al- buminuria and haematuria — Petechias — Convulsions — Coma, and death. Recent deposits upon the mitral valve — Splenic infarctions — Flabby anaemic liver — Ecchymoses upon the mucous mem- brane of the intestines, bronchi, &c. No. XI. {Page 118.) Exanthematic typhus — Jaundice — Albuminuria — Haemorrhage from the bovirels — Ecchymoses of the skin — Parotitis — Death on the twelfth day. Small spleen — Anasmic liver — Normal hepatic cells — Unobstructed bile ducts — No disease of the intestine, nor of the mesenteric glands. No. XII. {Page 120.) Petechial typhus — Jaundice — Albuminuria — Sup pression of urine — Right pneumonia — Dysentery — Death on the sev enth day. Lardaceous spleen of old date — Antemia of the liver — Exudation into the right lung — Dysentery — Recent exudation in the kid- neys. No. XIII, {Page 121.) Abdominal typhus — a severe rigor during con- valescence — Fresh enlarg'ement of the spleen — Great tenderness in the region of the liver, and afterwards of the entire abdomen — Jaun- dice — Dyspnoea — Somnolence — Deatli. Cicatrizing typhus ulcers in the ileum — Recent enlargement of the spleen — Round softened masses, of a brown color, and about an inch in diameter, in the liver — Bile ducts unobstructed — Peri- tonitis. No. XI Y. {Page 140.) Repeated attacks of lumbago in the seventh month of pregnancy — Gastric catarrh — Icterus — Delirium — Convul- sions — Coma — Death under symptoms of blood-poisoning. Acute atrophy of the liver — Complete disintegration of the hepatic cells — Crystalline deposits in the tissue of the liver and in the blood of the hepatic veins — Enlargement of spleen — Abortion. No. XY. {Page 142.) Symptoms of gastric catarrh and jaundice in the seventh month of pregnancy — Delirium — Convulsions and Coma — Abortion — Death on the seventh day of the disease. Acute atrophy of the liver — H;i?morrhage from the intestinal canal, and from the mucous membrane of the bronchi — Peculiar com- position of the urine. No. XYI. {Pagel^'^t.) Jaundice in the seventh month of pregnancy — Severe pains in the head — Great restlessness — Abortion — Yomiting of black fluid — Obstinate constipation — Coma — Petechise — Death eiglit days after the commencement of the jaundice. Acute atrophy of the liver — Small spleen — Fatty degeneration of, the kidneys — Abundance of leucine and tyrosine in the urine — Urea and leucine in the blood. APPENDIX. 225 No. XVII. {Page 150.) Symptoms of slight catarrhal jaundice, lasting fourteen days — On the fifteenth day sudden maniacal delirium; haemorrhage from the stomach and bowels, and death. Atrophy of the liver; its secreting cells partly disintegrated and partly in a state of fatty degeneration. No. XVIII. {Page 151.) Abdominal typhus — Profuse epistaxis — Violent delirium — Jaundice on the fifth day — Disappearance of the hepatic dulness — General muscular tremors — Coma — Death on the eighth day. Small, shrivelled liver, with partially disintegrated cells and empty bile ducts — Tumefaction of the spleen — Deposits in Peyer's patches, and in the solitary glands of the ileum. No. XIX. [Page 167.) Cancerous deposit in the duodenum — Occlusion of the ductus choledochus — Intense jaundice — Convulsions — Coma — Death. No. XX. {Page 170.) Ascites — Anasarca — Diarrhoea — Delirium — Coma. Cirrhosis of liver — Deposits of leucine in the hepatic veins — The central organs of the nervous system normal. No. XXI. {Page 171.) Ascites — Diarrhoea — Unconsciousness — Coma. Cirrhosis of the liver — Leucine in the blood and urine — Brain normal. No. XXII. {Page 172.) Jaundice of fourteen days' duration — Somno- lence — Vomiting — Sudden supervention of violent delirium — Coma —Death. Fatty degeneration of the liver in its most advanced form — En- largement of the spleen. No. XXIII, {Page 177.) Chronic atrophy of the liver, with considerable enlargement of the branches of the portal vein — A small ulcer at the pylorus, without any constriction — Distinct peristaltic movements of the stomach — Death from exhaustion. No. XXIV. {Page 182.) Tertian and quotidian intermittent of three months' duration — Anasarca — Ascites — Diarrhoea — Death from ex- haustion. Atrophied pigment-liver and pigment-spleen. No. XXV. {Page 183.) Persistent and oft-recurring quotidian inter- mittent — Hydra^mia — Anasarca — Ascites — Profuse diarrhoea — Death from exhaustion. Atrophy of the liver — Blocking-up of the capillaries by pigment. No. XXVI. {Page 184.) Atrophy of the liver with fatty infiltration — Dysenteric cicatrices — General dropsy. No. XXVII. {Page 185.) Chronic dysentery — Displacement of the intes- tinal canal — x^trophy of the liver — Death from exhaustion. No. XXVIII. {Page 180.) Fibrous thickening of tlie mesentery, with firm adhesions of the small intestine and of the omentum to the abdominal wall — Deposit of bluish-black pigment and cicatrizing ulcers in a coil of the small intestine, throe feet long — Chronic atrophy of the liver — Ascites and general dropsy. 226 APPENDIX. No. XXIX. {Page 188.) Violent dyspnoea — Bloody sputa — Systolic bruit over the pulmonary artery — Hajmorrhage from the stomach and bowels — Death from asphyxia. Occlusion of the pulmonary artery by a thrombus, in consequence of inflammation of the vessel — Coagulum of blood in the portal vein — Ecchymoses of the peritoneum, as well as of the mucous membrane of the stomach and bowels — Atrophy of the liver. No. XXX. {Page 191). Ulcer of the duodenum — Obliteration of por- tal vein by compression — Death in consequence of haemorrhage from the stomach and bowels — Liver and spleen of normal size. No. XXXI, {Page 218.) Persistent intermittent fever — Anaemia and hydrajmia — Exhausting diarrhoea, with but little bile in the stools — Death under cerebral symptoms. Fatty degeneration of the liver — Small lardaceous spleen — A lim- ited cancerous ulcer in the CECCum. a" 000 566 699 5 /=f7/3 v./ THE LIBRARY UNIVERSITY OF CALIFORNIA Santa Barbara THIS BOOK IS DUE ON THE LAST DATE STAMPED BELOW. Series 9482